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 Patient Existing Patient Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Preferred Nickname Address* 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 Communication Preference*EmailTextTelephoneMailPhone Number* Daytime PhoneCell PhoneEmail Address Personal InformationGender* Female Male Date of birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HiddenSocial Security Number (last 4 digits only!) HiddenDriver'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 LanguageEnglishSpanishOccupation Employer How were you referred to our office?Friend or FamilyFamily DoctorOphthalmologistInsurance CompanyNewspaperTelevisionRadioReceived MailingInternetOther OptometristOtherEye HistoryWhen, approximately, was your last eye exam? HiddenWhere did you get your last eye exam? Have you ever been diagnosed with any eye conditions* Yes No Please 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?* Yes No I stopped wearing glasses I 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?* Yes No I stopped wearing contact lenses I 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? Everyday A few days a week Special occasions For sports/ working out only When do you discard your contact lenses? Daily Every 2 weeks Monthly When they feel bad Please 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?* Yes No When were you diagnosed? MM slash DD slash YYYY Have you ever been diagnosed with any other medical conditions?* Yes No Please 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?* Yes No Please list all prescription and over-the-counter medications you're currently taking*Are you allergic to any medications?* Yes No Please 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?* Yes No Insurance Company's Name Member's Name First Last Who's insurance is the patient under?Member's Date of Birth Month Day Year Identification Number Group Number Member's Date of Birth MM slash DD slash YYYY Patient's Relation to Insured Member Vision InsuranceDo you have vision insurance?* Yes No Insurance Company's Name HiddenMember's Name First Last Who's insurance is the patient under?Identification Number or Last 4 digits of Member's SSN Group Number Member's Date of Birth MM slash DD slash YYYY Patient's Relation to Insured Member CommentsIf 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 CommentsThis field is for validation purposes and should be left unchanged.