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Patient Registration Form

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Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

 
Patient Information
Name
*
Address 1
*
Address 2
City
*
State / Province
*
Zip / Postal Code
*
Home Phone
*
Daytime Phone
Cell Phone
Pager Number
Fax Number
Email Address
 
Personal Information
Gender
*
Date of Birth (MM/DD/YYYY)
*
Provincial Health Care Number
Marital Status
Employment
Employer
Occupation
How were you referred to our office?
*

 
Eye History
Please check off any current conditions you suffer from

I stopped wearing glasses because:
I stopped wearing contact lenses because:
Headaches
Glare/Light Sensitivity
Tired Eyes
Amblyopia (lazy eye)
Burning
Dryness
Watery Eyes
Eye Pain and/or Soreness
Foreign Body Sensation
Infection of Eye or Lid
Itching
Mucous Discharge
Drooping eyelid(s)
Redness
Sandy or Gritty Feeling
Strabismus (crossed eye)
Blurred Vision at Distance
Blurred Vision at Near
Haloes
Double Vision
Floaters or Spots
Fluctuating Vision
Loss of Vision
Loss of Side Vision

 
Glasses History (Skip if you don't wear glasses)
What glasses do you own? Single Vision
Bifocals
Safety Glasses
Backup Glasses
Progressive
Trifocals
Sports Glasses
Sunglasses
Other
How many hours a day do you use a computer?

How many inches away, approximately, do you sit from your computer monitor?
Please check off any current conditions you suffer from

I am having problems with my current glasses
There are times when I would rather not be wearing glasses
I have problems with glare
I have problems with night vision
I am allergic to nickel (e.g. frames of glasses)
I don’t have spare set of glasses
My spare glasses have an incorrect prescription
My sunglasses are missing UV (ultra-violet) protection

 
Contact Lens History (Skip if you don't wear contacts)
What brand of contact lenses do you wear?
How old are your current lenses?
How often do you replace or dispose your contact lenses?
What brand of solution do you soak your lenses in?
What is your typical wearing schedule? Hours/day    Days/week
Please check off all that apply to you

I am having problems with my current contact lenses
There are times when I would rather not be wearing contact lenses
I am interested in changing or enhancing my eye color
I am interested in a non-surgical method of vision correction
I am interested in refractive laser surgery
I don't have a spare set of contact lenses
My spare contact lenses have an incorrect prescription

 
Medical History
When, approximately, was your last eye exam?
Where did you get your last eye exam?
When, approximately, was your last physical exam?
Who is your primary care physician?
Do you drink alcohol?
Do you smoke?
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
Please check off any current conditions you suffer from

Chronic fever, unexpected weight loss/gain, fatigue
Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)
Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)
Respiratory problems (eg. Shortness of breath, wheezing, coughing)
Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)
Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)
Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)
Skin problems (eg. Rashes, excessive dryness, growths or lumps)
Neurological problems (eg. Numbness, weakness, headaches, “blackouts”)
Psychiatric problems (eg. Depression, anxiety)
Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)
Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)
Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)

 
Primary Insurance
Please bring all insurance cards with you to your appointment.
Insurance Company Name
Insurance Company Phone Number
Address
Insured's Name
Identification Number
Group Number
Insured's Date of Birth
Patient's Relation to Insured
 
Secondary Insurance
If you have coverage through another plan/organization, please fill in the details below.
Insurance Company Name
Insurance Company Phone Number
Address
Insured's Name
Identification Number
Group Number
Insured's Date of Birth
Patient's Relation to Insured
 
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