Patient Registration Form

Patient Name *

Birthdate

Last 4 of SS#

Gender

MaleFemale

Address

Phone

Medical Insurance:

VIsion Insurance:

Policy Holder: Name & Birthdate

Other (please explain):

HISTORY OF PRESENT ILLNESS

FAMILY HISTORY
Has anyone in your family been diagnosed with: (select all that apply)

DiabetesHigh Blood PressureCancer

Has anyone been diagnosed with any of the following eye problems: (select all that apply)

SOCIAL HISTORY

CURRENT VISION

What type of contacts do you wear? Do you know the powers? How often do you replace your contact lenses?

Constitutional :

CancerFatigueDevelopmental disabilityN/A

Other (please explain):

Psychiatric:

Other (please explain):

Gastrointestinal Problems :

ColitisChron ' s diseasUlcerN/A

Other (please explain):

Genitourinary :

Prostate disease/cancerSTDKidney diseaseN/A

Other (please explain):

Musculoskelatal :

Other (please explain):

Skin :

RosaceaPsoriasisEczemaN/A

Other (please explain):

Endocrine :

Other (please explain):

Blood/Lymph :

Large volume blood lossAnemiaN/A

Other (please explain):

Allergy/Immunologic :

Other (please explain):

List any medicine allergies :

List any other allergies:

Current Medications

Please list all medications you are currently taking:

SURVEY TO BETTER SERVE YOU

Are your eyes sensitive to sunlight?

YesNo

Do you work at a computer?

YesNo

Interested in newer contact lens technology?

YesNo

Want information on thinner/lighter lenses?

YesNo

Problems with reflections and/or glare?

YesNo

Want information on LASIK vision surgery?

YesNo

Want a non-surgical option to LASIK?

YesNo

Do you spend time outdoors?

YesNo

Please list your sporting activities/hobbies:

Thank You!

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Patient Registration Form