Patient Registration and Medical History Form

Patient Information

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address City State ZipCode HI AL AK AZ AR CA CO CT DE DC FL GA ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY 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? My last eye examination was 1 year ago. My last eye examination was 2 years ago My last eye examination was 3 years ago My last eye examination was over 3 years ago 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? NO, I do not wear eyeglasses I do not know how old my prescription is My eyeglasses are 1 year old My eyeglasses are 2 years old My eyeglasses are over 3 years old Contact Lens Wearers Only Do you currently wear contact lenses? If "YES" , how long have you worn them? I have been wearing contacts for 1-5 years I have been wearing contacts over 5 years How many hours a day do you wear your contact lenses? 2 Hours 3 Hours 4 Hours 5 Hours 6 Hours 7 Hours 8 Hours 9 Hours 10 Hours 12 Hours 14 Hours 15+ hours Overnight 1 week 2 weeks 1 month How frequently do you replace your contact lenses ? (every 2 weeks, month, year, etc.) 2 weeks monthly daily weekly quarterly yearly When irritated When torn Never What contact lens solutions do you use? Any brand Aquify BioTrue Boston ClearCare Complete Costco/Kirkland Generic None Optifree Optifree Express Optifree Pure Moist Optimum Extra Pure Moist Renu Revitalens Unknown Lobob 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? Yes No Do you smoke? Never smoker (<100 lifetime cigarettes or equivalent quantity of cigar or pipe smoke) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other 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?