Patient Registration Form Please complete the information below and submit the form online or, if you prefer, print out the form after completion and bring it when you come to our office. This form contains confidential information that is delivered to your doctor through a secure Internet connection.Patient InformationAre you a new or existing patient?*New PatientExisting PatientName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Preferred 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Communication Preference*EmailTextTelephoneMailPhone Number*Daytime PhoneCell PhoneEmail AddressPersonal InformationGender*FemaleMaleDate of birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social Security Number (last 4 digits only!)Driver's License or State Identification numberRace*American Indian or Alaska NativeAsianBlack or African AmericanHispanicNative Hawaiian or Pacific IslanderWhiteDecline to specifyEthnicityDecline to specifyHispanic or LatinoNative Hawaiian or other Pacific IslanderNot Hispanic or LatinoPreferred LanguageEnglishSpanishOccupationEmployerHow were you referred to our office?Friend or FamilyFamily DoctorOphthalmologistInsurance CompanyNewspaperTelevisionRadioReceived MailingInternetOther OptometristOtherEye HistoryWhen, approximately, was your last eye exam?Where did you get your last eye exam?Have you ever been diagnosed with any eye conditions*YesNoPlease list any eye conditions you have ever been diagnosed with (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)Please check any conditions you suffer from currently Headaches Glare/Light Sensitivity Tired Eyes Amblyopia (lazy eye) Burning Dryness Watery Eyes Eye Pain and/or Soreness Foreign Body Sensation Infection of Eye or Lid Itching Mucous Discharge Drooping eyelid(s) Redness Sandy or Gritty Feeling Strabismus (crossed eye) Blurred Vision at Distance Blurred Vision at Near Haloes Double Vision Floaters or Spots Fluctuating Vision Loss of Vision Loss of Side Vision How many hours per day are you in front of a computer?Please enter a number from 0 to 24.Glasses HistoryDo you wear glasses?*YesNoI stopped wearing glassesI stopped wearing glasses because:What type of glasses do you own? Distance only Reading only Workstation Lined Bifocals or Trifocals No-line or Progressive Sunglasses Sports Safety OTC Readers Please check any current issues with your glasses. There are times when I'd rather not wear my glasses I have problems with glare or night driving I get headaches while reading or working at the computer My frames turn green or corrode easily I don’t have a second set of glasses My sunglasses don't seem to offer much protection It's time for some new glasses Contact Lens HistoryDo you wear contact lenses?*YesNoI stopped wearing contact lensesI stopped wearing contact lenses because:How old are the contact lenses you are currently wearing?What brand of contact lenses have you been wearing?What brand of solution do you clean your lenses in?How often do you use your contact lenses?EverydayA few days a weekSpecial occasionsFor sports/ working out onlyWhen do you discard your contact lenses?DailyEvery 2 weeksMonthlyWhen they feel badPlease check all that apply to you My current contact lenses are uncomfortable I have blurred vision in my current contact lenses I am interested in changing or enhancing my eye color with contact lenses I am completely out of contact lenses My current contacts are too expensive I'm interested in another brand of contacts Medical HistoryWhen, approximately, was your last physical exam?Who is your primary care physician?Are you diabetic?*YesNoWhen were you diagnosed? Date Format: MM slash DD slash YYYY Have you ever been diagnosed with any other medical conditions?*YesNoPlease list any other medical conditions you have ever been diagnosed with (High blood pressure, Arthritis, etc.)Please check any medical conditions you currently suffer from Chronic fever, unexpected weight loss/gain, fatigue Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat) Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet) Respiratory problems (eg. Shortness of breath, wheezing, coughing) Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting) Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems) Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints) Skin problems (eg. Rashes, excessive dryness, growths or lumps) Neurological problems (eg. Numbness, weakness, headaches, “blackouts”) Psychiatric problems (eg. Depression, anxiety) Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time) Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands) Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens) Please list any surgeries you've had:Are you currently taking any medications?*YesNoPlease list all prescription and over-the-counter medications you're currently taking*Are you allergic to any medications?*YesNoPlease list any drug allergies you have*Do you smoke?NoYes, occasionallyYes, 1/2 a pack per dayYes, 1 pack per dayYes, more than 1 pack per dayDo you drink alcohol?NoYes, 1 per weekYes, 1 per dayYes, 2 or 3 per dayYes, 4 or more per dayPlease list any family history (blood relatives) of medical or ocular conditions (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)Medical InsuranceDo you have Medical Insurance?*YesNoInsurance Company's NameMember's Name First Last Who's insurance is the patient under?Member's Date of Birth MM DD YYYY Identification NumberGroup NumberMember's Date of Birth Date Format: MM slash DD slash YYYY Patient's Relation to Insured MemberVision InsuranceDo you have vision insurance?*YesNoInsurance Company's NameMember's Name First Last Who's insurance is the patient under?Identification Number or Last 4 digits of Member's SSNGroup NumberMember's Date of Birth Date Format: MM slash DD slash YYYY Patient's Relation to Insured MemberCommentsIf you have any comments you would like to add, please enter them here.Privacy PolicyHealth Information Protection* I have read and agree to the Privacy Policy NameThis field is for validation purposes and should be left unchanged.