Adult Patient History & Registration

Adult Patient History & Registration

Adult Patient History & Registration

Adult Patient History & Registration

ADULT PATIENT HISTORY & REGISTRATION

Name

DOB
Gender
Preferred Noun
Address
Email Address
Home Phone
Cell Phone
Work Phone
Patient Status (Check all that apply)
Employer/School
Occupation

MEDICAL HISTORY

Family Physician
Phone Number
Date of Last Checkup
Please list the names of current medications (Rx and Over the Counter), including vitamins, eye drops, and birth control pills
Please list any allergies to medications, if applicable
Have you ever been diagnosed or treated for the following?
Do you have any blood relative with any of the above conditions?
Have you ever been hospitalized?

Eye History

Date of Last Eye Exam
Name of Last Seen Eye Doctor
Purpose for Today’s Visit
I wear my glasses for
I wear contacts for _ hours per day
Brand
Type
Have you ever been diagnosed or treated for the following?
Do you have any blood relative with any of the previous conditions?
Do you Smoke cigarettes?
If Yes, how often?
Do you Drink alcohol?
If Yes, how often?

EMERGENCY INFORMATION

Emergency Contact Name

Phone Number
Emergency Contact Relationship to Patient
How did you hear about us?

Adult Visual Checklist

Patient's Name

Age
Date
Symptoms (Please estimate how often the above-named exhibits the behaviors on this list.)
Normal indoor lighting is uncomfortable
Normal outdoor lighting is uncomfortable
Do you tend to “stare” without blinking?
Experience clumsiness/misjudge of where items really are
Drift to the right/left (circle right or left) when walking
Experience dizziness, balance problems, or motion sensitivity
Visually annoyed/distracted in a busy visual environment (ex: mall)
Poor recall or comprehension of information you that have just read
Difficulty concentrating while reading
Confuse/reverse/omit words/skip lines/lose place when reading
Experience headaches related to reading/computer
Experience side vision loss
Do you suffer from anxiety or from insomnia?
Experience double vision when viewing at a distance
Experience double vision when reading or close one eye
*Please fill out below if you have had an accident related brain injury or if you are involved in a law suit, or workers compensation case
Date of Accident/Injury
Briefly describe the accident and related injuries
Health Information Protection*
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