PATIENT REGISTRATION FORM
Please fill out completely. Insurance may not pay if we cannot provide all this information.
If a question is not applicable, please enter N/A.
PATIENT INFORMATION
last name
first name
M.i.
Nickname
social security #
date of birth
sex
Male
Female
Marital Status
Single
Married
Divorced
Widowed
Legally Separated
race
Asian
Decline to Specify
White
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Other Race
Ethnicity
Decline to Specify
Hispanic/Latino
Not Hispanic/Not Latino
Unknown
Mailing Address
city
state
zip code
email
physician you are seeing today:
Allison
Aman
Bochow
Cooper
Kiblinger
Lambson
Lash
Pennell
Prater
Whorff
Wick
referring physician
city
primary care physician
city
PERSON RESPONSIBLE FOR THE BILL (ONLY IF APPLICABLE IF OTHER THAN THE PATIENT)
last name
first name
m.i.
relationship to patient
Social Security #
Date of Birth
mailing address
city
state
zip code
home phone #
cell phone #
work phone #
ext.
INSURANCE INFORMATION
Primary insurance company
policy #
address
group #
policy holder name
RELATIONSHIP TO PATIENT
effective date
date of birth
sex
social security #
employer
ADDITIONAL PATIENT INFORMATION
Email
employment
Active Duty
Full-Time
Not Employed
Part-Time
Retired
Self
Where do you work?
what is your occupation?
Preferred language
English
Spanish
Other
Student
Full-Time
Part-Time
emergency contact NOT living with you (relative, neighbor, or friend)
relationship
Emergency contact: home phone #
cell phone #
other phone #
Spouse Full Name
Phone #
Caretaker Full Name
Phone
How did you hear about eyecare associates?
Family/Friend
TV
Radio
Newspaper
Yellow Pages
Doctor
Other
patient home phone #
patient cell phone #
patient work #
Preferred Contact By
Home Phone
Work Phone
Cell Phone
Is it okay to leave a detailed message?
Yes
No
patient d.l. #
patient cell phone #
Local pharmacy
address
mail-in pharmacy
ADDRESS
MEDICAL INFORMATION
date
referring physician
city
name
primary care physician
city
I. PAST MEDICAL HISTORY
medical history (do you have any of the following)
Asthma
Arthritis
Cancer
Breast Cancer
Colon Cancer
Leukemia
Lung Cancer
Lymphoma
Prostate Cancer
Diabetes
Emphysema (COPD)
Heart Disease
Atrial Fibrilation (irregular heartbeat)
Coronary Artery Disease
Hepatits
High Cholesterol (Hypercholesterolemia)
High Blood Pressure (Hypertension)
HIV
Stroke
Thyroid Disease
Hyperthyroidism
Hypothyroidism
Other
past surgical history
II. OCULAR HISTORY (List any eye conditions andor eye surgeries)
Eye conditions
eye surgeries
family history of
Cataracts
Crossed Eyes (Strabismus)
Diabetes
Eye Disorders
Glaucoma
Heart Disease
High Blood Pressure (Hypertension)
Lazy Eyes (Amblyopia)
Retinal Detachments
Other
III. CURRENT MEDICATIONS
IV. MEDICATION ALLERGIES
V. SOCIAL HISTORY
drug use
alcohol use
None
Less than 1 drink per day
1-2 drinks per day
3 or more drinks per day
Smoking status
Current every day smoker
Current some days smoker
Former smoker
Never smoked
VI. REVIEW OF SYSTEMS (Do you have any problems in the following areas? Check all that apply)
1) General health
Normal
Fever
2) Eyes
Normal
Blurred Vision
3) Ears, nose, mouth, throat
Normal
Hearing Loss
4) Cardiovascular
Normal
Chest Pain
5) respiratory
Normal
Short of Breath
6) gastrointestinal
Normal
Stomach Pain
7) hematologic/lymphatic
Normal
Free Bleeder
8) musculoskeletal
Normal
Weakness
9) integumentary (skin/breast)
Normal
Tumors
10) neurologic
Normal
Numbness
11) genitourinary
Currently Pregnant