Hidden

Date

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Work Phone

Cell Phone*

Email*

Birthday*

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*

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. **

Signature

About Your Visit

DEAR 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)*

please list

2. Please check those activities in which you participate

3. How many times a day do you use the computer?*

History Questionnaire

Primary Care Physician*

Were you referred?

Yes

by whom?

Medications

LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING: (including eye drops, vitamins, supplements etc...)

Allergies to medication or food

OCULAR HISTORY

Please check yes or no and explain all that apply.

Blurred, Distorted or Double Vision

Please explain

Loss of Vision or Fluctuation of Vision

Please explain

Mucous Discharge

Please explain

Floaters/ Flashes

Please explain

Pain/ Soreness

Please explain

Chronic infection

Please explain

Eye Surgery

Please explain

Other

Please explain

Review of Systems

Please 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

Respiratory Systems: (lungs, breathing)

Asthma, emphysema, TB
Shortness of breath

Please explain

Gastrointestinal: (stomach, intestine)

Jaundice, hepatitis, ulcers
Hernia, reflux, GI bleeding

Please explain

Genitourinary: (genital, kidney, bladder)

Kidney disease, pain
Frequent urination

Please explain

Integumentary: (skin and/or breast)

Skin disease, skin cancer

Please explain

Musculo-skeletal

Degenerative arthritis
Rheumatoid arthritis
Lupus/ Other

Please explain

Neurological

Fainting, dizziness
Migraines, seizures
Stroke, paralysis

Please explain

Psychiatric

Depression
Schizophrenia/ Other

Please explain

Hematologic / Lymphatic

Anemia, sickle cell
Bleeding disorder
Leukemia/ Other

Please explain

Allergic/ Immunologic

Seasonal allergies
Immune disorder
Hay fever/ other

Please explain

Endocrine

Diabetes, Type I
Diabetes, Type 2
Thyroid
Hormone replacement
HIV/ AIDS

Please explain

Describe any other problems, illnesses, or conditions that were not previously mentioned

List of past surgeries

Date	Type

FAMILY HISTORY

Do 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 History

Do you drink alcohol?

Yes
No

Please explain

Do you smoke?

Yes
No

Please explain

Patient Registration Form

Please complete either of the following

About Your Visit

DEAR PATIENT:

History Questionnaire

Medications

OCULAR HISTORY

Review of Systems

List of past surgeries

FAMILY HISTORY

Wendy Waguespack,OD