Online Patient Registration Form Name First Last PhoneEmail Optional Test I would like to have both additional screening tests done I would like to have just the retinal photographs taken I would like to have just the visual field test done I would I would not like to have either optional test done How did you hear about us? Previous Patient Referred by friend/family Referred by insurance Walk-in Advertisement Whom may we thank:Advertisement Valpak Merchandiser Gazette Giant Courier VOU message board Other OtherSocial HistoryRecreational Activities: Sports (indoor) Sports (outdoor) Video games Reading Alchohol Consumption: Video games Computer Use Tobacco Consumption Sports (indoor) FrequencySports (outdoor):FrequencyVideo games: FrequencyReading: FrequencyAlcohol Consumption: FrequencyTobacco Video Games: FrequencyComputer Games: FrequencyPatient Comments:Glasses and Contact Lenses Glasses for distance only Glasses for near/reading only Glasses for full-time wear Soft contact lenses Rigid contact lenses No previous glasses or contact lenses Check all that apply and explainExplainLaser or Eye SurgeryCheck all that apply and explain NO laser or ocular surgery ExplanationPast Eye Conditions and InjuriesCheck all that apply and explain NO past illnesses or injuries Conditionsor Injuries:Eye MedicationsCheck all that apply and explain NO personal eye medications ExplanationPersonal Eye DiseasesCheck all that apply and explain NO personal eye diseases Cataracts Glaucoma Detached Retina Diabetic Retinopathy Macular Degeneration Turned Eye (strabismus) Lazy Eye Eye Injury Other ExplanationFamily Eye DiseasesCheck all that apply and explain NO family eye diseases Cataracts Glaucoma Detached Retina Diabetic Retinopathy Macular Degeneration ExplainGeneral Health HistoryCheck all that apply and explain Fever or weight loss Ears, mouth, nose, throat problems Sinus disease High blood pressure Irregular heart beat Other heart disease Asthma or emphysema Other lung disease Diabetes or thyroid disease Stomach or intestinal problems Kidney, urinary or genital disease Joint or muscle pain Skin disorders Headaches Stroke or neurological disease Blood disorders HIV or AIDS Seasonal allergies Reaction to anesthetics Psychiatric problems Do you smoke cigarettes Other current health problems ExplanationCurrent MedicationsCheck all that apply and explain NO current medications ExplanationAllergies to MedicinesCheck all that apply and explain NO allergies to medicines Allergy:Past Surgeries (cardiovascular/brain/thyroid)Check all that apply and explain NO past surgeries Past Surgeries:Family Medical DiseasesCheck all that apply and explain NO family medical diseases Family high blood pressure Family cancer Family neurological disease Family diabetes Explanation
