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.

Patient Information

TitleFirstLastMISuffixNickname
Address:

CityStateZipCode
Home Phone:
Work Phone:
Other Phone:
Cell Phone:
Email
Preferred Contact Method:
Birthday (mm/dd/yyyy)
Sex Male Female
Race:
Ethnicity:
Preferred language:
Marital Status
Employment Status Employed Full-Time Student Part-Time Student
Occupation
Employer/School Name
Parent/Guardian
Who may we thank for referring you to our office?

Billing Information

Check this box if the Billing Address is the different? Please make changes to your billing address.

TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Patient Ocular History

List any vision complaints 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
When was your last eye exam?

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

Please list any EYE medications you are taking.
Please list any OVER THE COUNTER eye drops you are using.
Please list any EYE surgeries you have had.
Do you currently wear eyeglasses? If "YES", How long have you had the current prescription?
Contact Lens Wearers Only
Do you currently wear contact lenses? If "YES" , how long have you worn them?
How many hours a day do you wear your contact lenses?
How frequently do you replace your contact lenses ? (every 2 weeks, month, year, etc.)
What contact lens solutions do you use?

Medical History

What is the name of your primary care physician?

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:

Please list any allergies to medications.
List any surgeries you have had (cataract, tonsillectomy, appendectomy, etc) :
Are you pregnant or nursing?
Do you smoke?

Review of Systems

Do you have any of the following medical conditions?
GENERAL HEALTH: Fever, weight loss, weight gain, fatigue? NO
SKIN: Growths, rashes, acne NO
NEUROLOGICAL: Headaches, migraines, seizures. NO
ENDOCRINE: Thyroid, diabetes. NO
EAR, NOSE THROAT: Allergies, sinus, cough, dry mouth/ throat. NO
RESPIRATORY: Asthma, bronchitis, emphysema, COPD. NO
CARDIOVASCULAR: High blood pressure, heart surgery, vascular disease. NO
GASTROINTESTINAL: Diarrhea, constipation, ulcer, reflux. NO
GENITAL, KIDNEY, BLADDER: Kidney stones, frequent urination, impotence. NO
MUSCLES, BONES, JOINTS: Arthritis, joint pain, head or neck injury. NO
BLOOD /LYMPH :Anemia, cholesterol, bleeding problems. NO
ALLERGIC / IMMUNOLOGIC : Seasonal allergies, rheumatoid arthritis, AIDS, Lupus, allergy shots. NO
PSYCHIATRIC: Depression, anxiety, insomnia. NO

Ready to submit your information?