Patient Registration and Medical History Form

Thank you for using our secure online forms. Please fill out as much information as you can. When you are finished be sure to hit the submit button at the bottom of the form. If you have any questions, please call us at (808) 949-2662. We can always change the data in the office if you are unsure about what to enter in any of the fields.


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Billing information

If yes, please provide the billing address information below

Please choose from the menu options or select the option to type in your own text. Thank you!

Patient Ocular History

What is the reason for todays exam. List any vision symptoms you are having:

  •      • blurred vision, headaches, eyestrain, double vision, or losing your place when reading
  •      • itching, burning, redness, pain, sensitivity to light, watering, crusting or mucus discharge
  •      • seeing rainbows around white lights at night, flashes of light or dark spots/squiggles/webs


Check the box for any conditions that apply:

You Mom Dad Sib Describe (type, when diagnosed, which eye(s), treatment,etc)
Glaucoma
Macular Degeneration
Retinal problems
Cataracts
Lazy Eye/Eye Turn

Contact Lens Wearers Only

Medical History


Check the box for any conditions that apply:

You Mom Dad Sib Describe (type, when were you diagnosed, etc)
Hypertension
Thyroid
Cardiovascular
Cancer
Diabetes

Please list any MEDICATIONS you are taking.

Review of Systems