This is the page for all Personal, Insurance and
Medical Information necessary to register you as a patient.

The first section is for your Personal and Insurance Information and
the second section is for your Medical History. Please click on the
submit button at the bottom when you have completed your form.

Click here to return to the HOMEPAGE or to go to the RESOURCES PAGE.

First Section: Insurance Information
The Asterisk Boxes* Are Required Information

If the submit button at the bottom does
not work, please go back and complete the
RED-HIGHLIGHTED necessary text boxes.

 
Full Name *
A value is required.Invalid format.
Today's Date (mm/dd/yy)
Your Appointment Date
Appointment Time
Full Home Address
Married Status (select)
Date of Birth* (mm/dd/yy) A value is required.
Age
Male/Female (select)
Social Security Number
Contact Phone* .
Business Phone
Cell or Mobile Phone
*Medicare and Private Insurance now require the next five
items to be completed with your information or enter the
word "Declined." Race
Preferred Language
Ethnicity
Height Weight
Occupation
Employer Phone
Employer Address
Email Address
Driver's License #
Emergency Contact Name, Phone and Relationationship
Referred By* A value is required.Invalid format.
 
 
Commercial Insurance - Primary Insured
Check if same as above
Name of Insured
Relationship
Date of Birth
Social Security #
Insurance Company
Group Number
Policy Number
Insurance Company Address
   
ELECTRONIC PRESCRIPTION SERVICE
 
Please provide at least cross streets and a pharmacy name.
Any other details will help speed up your electronic Rx.
Pharmacy Name
Pharmacy Address
Pharmacy Phone
   
Medicare - Medicaid
Medicare #
Medicaid #
Supplemental Insurance Company Address
Suppl Insurance Co. Phone
Subscriber ID #
Group #
For Medicare to Cover Your Visit, You Must Have
a Medical Reason Such as Pain, Blurred vision, etc.
   
Second Section: Medical History
Reason For Your Visit* A value is required.Invalid format.
   

Family History

Please list any diseases or disorders that have occurred in your immediate family. That includes your grandparents, parents, siblings and children.

Disease/Disorder and Relationship

Medications

Name, Dosage and Frequency.

Medication or Food Allergies

If you have additional Family History, medications or allergy information, please list those items on a separate piece of paper and bring it with you when you visit our office.
Social Habits

Do you smoke? Y N

If Yes, how much?

If stopped, when?

Alcohol Y N

If Yes, how much and frequency?

Symptoms, Past Medical History, Previous Ocular History and Review of Systems

Please check only the positive responses.

Chief Complaint

vision change blurry vision broken blood vessel

bump on eyelid burning sensation cataract blurry

chemical burn chronic irritation cloudy vision

contact lens irritation cyst on eyelid diabetes

difficult reading print discharge distorted vision

double vision dryness eyes tire failed DMV test

film over eye flashes of light floaters

fluctuating vision foreign body sensation freckle

glare from lights glasses problem glaucoma

glaucoma suspect gritty feeling growth on eye

hard to focus headache injury iritis

irritation itching keratoconus lids stuck together

light sensitive long-term risk medication

macular degeneration macular pucker migraines

ocular hypertension pain in or around eye

plaquenil use poor night vision redness

routine exam school request second opinion

shingles skim over vision stye swelling

tearing trouble driving at nightt twitching of eyelid

veil or cloud in vision other

Medical History

ADD acid reflux acne allergies alzheimer's

anemia anxiety arthritis asthma

autoimmune disorder bell's palsy bleeding tendency

blood disorder cancer central nervous system

cholesterol elevated cluster headache colitis

depression diabetes type I diabetes type II

diverticulitis drug allergies eczema fibromyalgia

gout hand tremor heart disease hepatitis

herniated disc hypertension irregular heart rate

kidney stones lupus erythematosus melanoma

migraines multiple sclerosis neuropathy

osteoporosis/osteopenia parkinsonism plaquenil Rx

prostate problem psoriatic arthritis

respiratory problems rheumatoid arthritis

rosacea sarcoidosis seizure disorder

shortness of breath sjoegren's syndrome sleep apn

spine disc compression surgery swelling

thyroid trouble trans. ischemic attack tuberculosis

ulcerated colon ulcers other

Previous Ocular History

amblyopia astigmatism baggy eyelids

blepharitis blindness cataract conjunctivitis

color blind contact lens wear corneal problem

cranial nerve palsy crossed eyes diab. retinopathy

double vision dry eyes elevated eye pressure

farsightedness flashes of light foreign body

freckle in eye glaucoma glaucoma suspect

hereditary eye condition intraocular lens surgery

iritis keratitis keratoconus lasik

macular degeneration macular pucker migraines

nearsightedness night vision problem

ocular migraine presbyopia pterygium ptosis

punctum plug recurrent erosion radial keratotomy

retinal problem shingles strabismus stye

tearing trauma vitreous detachment

wear contacts wear glasses

other

Cardiology History

ankle swelling atrial fibrillation by-pass surgery

chest pain cholesterol elevated

congestive heart failure enlarged heart heart dis.

heart murmur heart valve repl. high blood pressure

irregular heartbeat mitral valve prolapse

obstructive sleep apnea pacemaker palpitations

poor circulation rheumatic fever shortness of breath

stents supraventricular tachycardia syncope

other

Ear, Nose, Mouth and Throat History

congestion cough (dry) cough with sputum

dentures dry throat/mouth dysphagia

ear disorder hard of hearing head injury

hoarseness jaw claudication meniere's disease

nosebleeds plugged ears poor dentistry

runny nose sinus problems sore throat

sore teeth other

Endocrine History

depression diabetes type I diabetes type II

diabetes type II - insulin excessive sweating

grave's disease hair loss hyperthyroidism

hypoglycemia hypothyroidism obesity

pancreatitis pituitary problem postmenopausal

thyroid problem weight gain weight loss

other

Gastrointestinal History

acid reflux barrett's esophagitis black tarry stools

bloating change in stool color colitis

constipation crohn's disease diarrhea

diverticulitis food intolerances gastroparesis

gerd heartburn hemorrhoids hiatal hernia

indigestion irritable bowel syndrome lazy bowel

liver trouble nausea use of laxatives ulcer

vomiting other

Genitourinary History

blood in urine change in frequency dysuria

female disorders genital discharge hesitancy

high frequency of urination high volume of urination

impotence incontinence kidney disease

kidney problems kidney stones kidney transplant

male disorders nocturia prostate cancer

prostate enlargement urgency venereal disease

other

Hematologic/Lymphatic History

anemia bleeding tendencies blood clots

blood disorders blood dyscrasia bruising tendency

chronic lymphocytic leukemia hemochromatosis

high blood calcium hepatitis B lymphadenopathy

platelet disorder sickle cell anemia thalassemia

other

Integumentary History

acne birth marks cancer change in hair or nails

change in pigmentation cold sores of lips dandruff

dry skin dryness eczema foot sores

fungus infection herpes simplex lichen planis

lumps poison ivy rash pruritis (itching)

psoriasis rosacea seborrhea shingles

skin rash other

Musculoskeletal History

arthritis claudication (interm) cramps

deep vein thrombosis gout fibromyalgia

osteoarthritis osteopenia osteoporosis

pain psoriatic arthritis rheumatoid arthritis

scleroderma sjoegren's syndrome swelling

systemic lupus erythematosus varicosities

other

Neurological History

alzheimer's bell's palsy blackouts brain tumor

cluster headaches dementia dizziness

fainting forgetfulness guillain barre

local weakness migraine headache neurodermatitis

numbness paralysis parkinsonism

poor coordination poor memory

proximal muscle weakness restless leg syndrome

seizures speech difficulty stroke

tingling of extremities other

Psychiatric History

anxiety ADD bipolar dementia depression

eating disorder manic-depressiveness nervousness

neuroses poor memory psychoses

schizophrenia sleeping difficulty suicidal ideation

tension other

Respiratory History

asthma emphysema chronic bronchitis

chronic cough chronic obstructive pulmonary disease

cough cough (dry) dyspnea on exertion

orthopnea reactive airways shortness of breath

sleep apnea tuberculosis

other

Constitutional Symptoms

fever headache jaw claudication malaise

night sweats scalp tenderness weakness

weight gain weight loss

other

 

 
   
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