Patient Registration Form Please complete either of the following Print and fill out the New Patient Paperwork, click here Complete the online patient history below. HiddenDate MM slash DD slash YYYY Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneCell Phone*Email* Birthday* MM slash DD slash YYYY Social Security #*Marital Status* S M D W Spouse Name The person responsible for billing:* I am Someone else PERSON RESPONSIBLE FOR BILL* Address* Street Address Address Line 2 City ZIP / Postal Code Birthday* MM slash DD slash YYYY Phone Number*YOUR SIGNATURE ON THIS FORM WILL SERVE AS OUR “SIGNATURE ON FILE” FOR INSURANCE FORMS **IF YOU HAVE INSURANCE OUR OFFICE WILL BILL AND ACCEPT PAYMENT DIRECTLY FROM THEM IF THE SERVICES QUALIFY FOR COVERAGE. ANY CHARGES NOT COVERED ARE PAYABLE BY THE PATIENT. YOUR SIGNATURE HERE WILL SERVE AS YOUR AGREEMENT TO PAY FOR SERVICES AND MATERIALS NOT COVERED. ** SignatureAbout Your VisitDEAR PATIENT: So that we may better meet your vision care needs, please complete the questions below regarding your visit to our office and your participation in hobbies, sports, and computer usage.1. Your reason(s) for visiting our office today: (Please check appropriate items)* General check-up Lost or broken eyeglasses Want new eyeglasses Want contact lenses Soft disposable Light sensitive Bifocal contact lenses Gas permeable Blurred distance vision Blurred near vision Eyes feel tired Double vision Headaches Golf glasses Eyes water Eyes itch Eyes feel dry Pain in eyes Night vision Interested in Lasik Other please list 2. Please check those activities in which you participate Golfing Basketball Skiing Football Baseball/Softball Tennis/Racquetball Soccer Hunting Fishing Swimming Bowling Volleyball Biking TV Walking/Jogging Rollerblading Dancing Aerobics Reading Gardening Crafting Musical Scuba Sewing Woodworking Instrument Boating 3. How many times a day do you use the computer?* History QuestionnairePrimary Care Physician* Were you referred? Yes by whom? MedicationsLIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING: (including eye drops, vitamins, supplements etc...) Allergies to medication or food OCULAR HISTORYPlease check yes or no and explain all that apply. Blurred, Distorted or Double VisionPlease explain Loss of Vision or Fluctuation of VisionPlease explain Mucous DischargePlease explain Floaters/ FlashesPlease explain Pain/ SorenessPlease explain Chronic infectionPlease explain Eye SurgeryPlease explain OtherPlease explain Review of SystemsPlease check yes or no and explain all that apply. Constitutional Systems Fever, weight loss, other Please explain Ears, Nose, Mouth, Throat Hearing or sinus problems Please explain Cardiovascular System High blood pressure High Cholesterol Heart disease/heart attack Heart surgery/Other Please explain Please explain Please explain Please explain Respiratory Systems: (lungs, breathing) Asthma, emphysema, TB Shortness of breath Please explain Please explain Gastrointestinal: (stomach, intestine) Jaundice, hepatitis, ulcers Hernia, reflux, GI bleeding Please explain Please explain Genitourinary: (genital, kidney, bladder) Kidney disease, pain Frequent urination Please explain Please explain Integumentary: (skin and/or breast) Skin disease, skin cancer Please explain Musculo-skeletal Degenerative arthritis Rheumatoid arthritis Lupus/ Other Please explain Please explain Please explain Neurological Fainting, dizziness Migraines, seizures Stroke, paralysis Please explain Please explain Please explain Psychiatric Depression Schizophrenia/ Other Please explain Please explain Hematologic / Lymphatic Anemia, sickle cell Bleeding disorder Leukemia/ Other Please explain Please explain Please explain Allergic/ Immunologic Seasonal allergies Immune disorder Hay fever/ other Please explain Please explain Please explain Endocrine Diabetes, Type I Diabetes, Type 2 Thyroid Hormone replacement HIV/ AIDS Please explain Please explain Please explain Please explain Please explain Describe any other problems, illnesses, or conditions that were not previously mentionedList of past surgeriesDateType FAMILY HISTORYDo you have a family history of: Diabetes Yes No Family member Glaucoma Yes No Family member Macular degeneration Yes No Family member Retinal detachment Yes No Family member Other eye diseases Yes No Family member Social HistoryDo you drink alcohol? Yes No Please explain Do you smoke? Yes No Please explain