Patient Registration Form Today's Date* MM slash DD slash YYYY Name* First Middle Last NicknameAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth* MM slash DD slash YYYY Birth Sex Female Male Home PhoneCell PhoneWork PhoneEmail Social Security Number (last 4 digits only!)Please enter a number from 0000 to 9999.OccupationSpecial NeedsComputer UsageHobbies/SportsParents/Gurdians First Last RelationshipAlt. ContactFamily DoctorDoctor's Phone NumberPrimary Phone NumberAlternate Phone NumberLast Medical Exam MM slash DD slash YYYY Last Eye Exam MM slash DD slash YYYY Note: For dates where exact date is unknown. Please use a number that is as close as you can remember. Note to Patient: Only check those items you are experiencing or think you might be. You don't have to click the No Review of SystemsDo you currently or have you ever had any problems in the following areas:CONSTITUTIONALYesNo?FeverWeight Gain/LossINTEGUMENTARYYesNo?SkinNEUROLOGICALYesNo?HeadachesMigrainesSeizuresEYESYesNo?Loss of VisionBlurred VisionDistored Vision/HalosLoss of Side VisionDouble VisionDrynessMucous DischargeRednessItchingBurningForeign Body SensationExcess TearingGlare / Light SensitivityEye Pain or SorenessChronic Infection of Eye or LidStyes or ChalazionFlashersFloaters in VisionTired eyesColor blindRESPIRATORYYesNo?AsthmaChronic BronchitisEmphysemaSleep ApneaEARS, NOSE AND THROATYesNo?Allergies / Hay FeverSinus CongestionRunny NosePost-Nasal DripChronic CoughDry Throat / MouthRinging In EarsEar Pain or InfectionHearing AidsDeafVASCULAR, CARDIOVASCULARYesNo?DiabetesHeart DiseaseHigh Blood PressureHigh CholesterolGASTROINTESTINALYesNo?DiarrheaConstipationGENITOURINARYYesNo?Gonads / Kidneys / BladderBONES / JOINTS / MUSCLESYesNo?Rheumatoid ArthritisMuscle PainJoint PainLYMPHATIC / HEMATOLOGICALYesNo?AnemiaBleeding ProblemsENDOCRINEYesNo?Thyroid / Other GlandsALLERGIC, IMMUNOLOGICYesNo?PSYCHIATRICYesNo?If you answered " ? " to any of the above or have a condition not listed, please explain.Medical HistoryDo you have any allergies To Medications? Yes No If Yes, ExplainList any medications you take (including oral contraceptives, asprin, over the counter medications and home remedies)List all major injuries, surgeries and/or hospitalizations you have hadCheck Any of the following that you have had Prominent Eyes Crossed Eyes Lazy Eye Eye Infections Retinal Disease Glaucoma Cataracts Eye Injury Drooping Eyes Are you pregnant? No Yes Do you wear glasses? No Yes how old is your present pair of glasses?Do you wear contact? No Yes If Yes, how old is your present pair of lenses?Type of Contact Lenses Rigid Soft Extended Wear Other Are they comfortable? No Yes Family HistoryPlease note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditionsBlindness Yes No Family Member RelationshipCataract Yes No Family Member RelationshipGlaucoma Yes No Family Member RelationshipCrossed Eyes Yes No Family Member RelationshipMacular Degeneration Yes No Family Member RelationshipRetinal Detachment or Disease Yes No Family Member RelationshipArthritis Yes No Family Member RelationshipCancer Yes No Family Member RelationshipDiabetes Yes No Family Member RelationshipHeart Disease Yes No Family Member RelationshipHigh Blood Pressure Yes No Family Member RelationshipHigh Cholesterol Yes No Family Member RelationshipKidney Disease Yes No Family Member RelationshipLupus Yes No Family Member RelationshipThyroid Disease Yes No Family Member RelationshipOther Yes No Family Member RelationshipIf Other, please explain:If Yes to any of the above, please explain:Social HistoryThis information is kept strictly confidential. However you discuss this portion directly with the doctor if you preferI WOULD PREFER TO DISCUSS MY SOCIAL HISTORY INFORMATION DIRECTLY WITH MY DOCTOR. Yes Do you drive? Yes No If Yes, do you have visual difficulty when driving? Yes No If Yes, please describe:Do you use tobacco products? Yes No If Yes, type/amount/how long:Do you drink alcohol? Yes No If Yes, type/amount/how long:Do you use illegal drugs? Yes No If Yes, type/amount/how long:Have you ever beeen exposed to or infected with: Gonorrhea Hepatitis Syphillis HIV/AIDS SignatureDate MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Δ
