New Patient Registration Form

Medical History Form

Please fill out the form below with your personal information & medical history. Thank you!
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Work Phone Number

Area CodePhone Number
E-mail
PERSONAL INFORMATION
Gender*
Date of Birth*

MonthDayYear
Date
Social Security #
Occupation*
Race/Ethnicity
Preferred Language
INSURANCE INFORMATION

Please fill out the details for each section that applies to you. If you do not have Medical or Vision Insurance, leave blank and skip ahead to the next section.
MEDICAL INSURANCE DETAILS:
Medical Insurance Provider
Medical Insurance Policy Number*
Medical Insurance Group Number
Medical Insurance Responsible Party or Subscriber Name*
Insurance Subscriber Date of Birth*

MonthDayYear
Date
VISION INSURANCE DETAILS:

If you do not have Vision Insurance, please skip this section.
Vision Insurance Provider
Vision Service Plan (VSP) requires the subscriber's Social Security number to verify eligibility.
Vision Insurance Policy Number (Subscriber's SSN)
Vision Insurance Group Number
Vision Insurance Responsible Party or Subscriber Name
Insurance Subscriber Date of Birth

MonthDayYear
EMERGENCY CONTACT
Emergency Contact:*

First NameLast Name
Relationship*
Contact Number*

Area CodePhone Number
MEDICAL HISTORY
Date of Last Eye Exam

MonthDayYear
Date
Name of Your Medical Doctor
Doctor's Phone Number
Date of Last Medical Exam

MonthDayYear
Date
Do you have any allergies to medications?*

YesNo
If Yes, please explain...
List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies)
List all major surgeries, injuries, and/or hospitalizations you've had...
Check any of the following that you have had...

Crossed EyesLazy EyeDrooping EyelidProminent EyesGlaucomaRetinal DiseaseCataractsEye InfectionsEye Injury
Are you pregnant or nursing?

YesNo
Do you wear glasses?*

YesNo
If yes, how old is your present pair of lenses?
Do you wear contact lenses?*

YesNo
If yes, how old is your present pair of contact lenses?
Type of contact lenses you wear:

RigidSoftExtended WearOther
Are they comfortable?

YesNo
FAMILY HISTORY
Note any family history (parents, grandparents, siblings, children; living or diseased) for the following conditions...

BlindnessCataractCrossed EyesGlaucomaMacular DegenerationRetinal Detachment or DiseaseArthritisCancerDiabetesHeart DiseaseHigh Blood PressureKidney DiseaseLupusThyroid DiseaseOther
If you have checked anything above, please not the relationship to you.
SOCIAL HISTORY
This information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer.*

I will fill out the information belowI would like to discuss directly with the doctor
Do you able to drive?

YesNo
Do you have visual difficulty when driving?

YesNo
Do you use tobacco products?

YesNo
If yes, type/amount/frequency?
Do you drink alcohol?

YesNo
If yes, type/amount/frequency?
Do you use illegal drugs?

YesNo
If yes, type/amount/frequency?
Have you ever been exposed or infected with:

GonorrheaHepatitisHIVSyphilis
REVIEW OF SYSTEMS

Do you currently, or have you ever had any problems in the following areas?
EYES

Loss of VisionBlurred VisionDistorted Vision/HalosLoss of Side VisionDouble VisionEye DrynessMucous DischargeRednessSandy or Gritty FeelingItchingBurningForeign Body SensationExcess Tearing/WateringGlare/Light SensitivityEye Pain or SorenessChronic Infection, Eye or LidSties or ChalazionFlashes/Floaters in VisionTired Eyes
CONSTITUTIONAL

Fever, Weight Loss/Gain
INTEGUMENTARY

Skin
NEUROLOGICAL

HeadachesMigrainesSeizures
ENDOCRINE

Thyroid/Other Glands
EARS/NOSE/MOUTH/THROAT

Allergies/Hay FeverSinus CongestionRunny NosePost-Nasal DripChronic CoughDry Throat/Mouth
RESPIRATORY

AsthmaChronic BronchitisEmphysema
VASCULAR/CARDIOVASCULAR

DiabetesHeart PainHigh Blood PressureVascular Disease
GASTROINTESTINAL

DiabetesHeart PainHigh Blood PressureVascular Disease
GENITOURINARY

GenitalsKidneyBladder
BONES/JOINTS/MUSCLES

Rheumatoid ArthritisMuscle PainJoint Pain
LYMPHATIC/HEMATOLOGIC

AnemiaBleeding Problems
ALLERGIES

AllergicImmunologic
PSYCHOLOGICAL

Psychiatric
If you have checked ANY of the boxes above or have a condition not listed, please explain and list all medications:
Should be Empty:

Medical History Form