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*4PC Template – Patient info w/ins. & med
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2020-05-22T17:27:25+00:00
*4PC Template - Patient info w/ins. & med
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2
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Patient Registration
Title
Mr.
Ms.
Miss
Mrs.
Dr.
Other
Please specify
Name
*
First
Last
Nickname
Date of Birth
*
MM slash DD slash YYYY
Age
Sex
Male
Female
Marital Status
Single
Married
Divorced
Widowed
Home Phone (or Cell if no home)
*
Cell Phone
Work Phone
Social Security Number
XXX-XX-XXXX
Email
*
Do You Wear Contacts?
*
Yes
No
Would You Like Text Reminders?
Yes
No
Family Physician Phone Number
Emergency Contact
Mr.
Mrs.
Miss
Ms.
Dr.
Prefix
First
Last
Home Phone
Cell Phone
Emergency Contact's Relationship to Patient
How Did You Hear about Us?
Insurance
Web Search
Facebook
Yelp
Yahoo
Google
Friend
Other
Name
First
Last
Other: Please Specify
Employment Information
Occupation
Status
Full-time
Part-time
Retired
Not Employed
Employer
Employer Phone
Vision Insurance Information
(1st) Primary Insurance
ID Number
Subscriber's Name
First
Last
Plan Number
Subscriber's Birth Date
MM slash DD slash YYYY
Patient's Relationship to Subsriber
Self
Spouse
Child
Other
Other: Please Specify
Please scan and upload both sides of your insurance card
Drop files here or
Select files
Max. file size: 512 MB.
Medical Insurance Information
(1st) Primary Insurance
ID Number
Subscriber's Name
First
Last
Plan Number
Subscriber's Birth Date
MM slash DD slash YYYY
Subscriber's SSN
Patient's Relationship to Subsriber
Self
Spouse
Child
Other
Other: Please Specify
Medical Information
Patient/Guardian Name
First
Last
Date of Birth
MM slash DD slash YYYY
Current Medical Problems
Select All That Apply
Allergy/Immunologic (e.g., Hives, Eczema, Rash, Lumps)
Cardiovascular (e.g., Chest Pain, Palpitations, Difficulty Breathing, Endema)
Constitutional (e.g., Fever, Chills, Weight Gain, Weight Loss)
Endocrine (e.g., Heat/Cold Intolerance, Frequent Urination, Thirst, Appetite)
Gastrointestinal (e.g., Heartburn, Nausea, Constipation, Diarrhea)
Ear/Nose/Mouth/Throat (e.g., Decreased Hearing, Discharge, Dryness, Hoarseness)
Hematologic (e.g., Bruising, Bleeding, Anemia)
Integumentary (e.g., Moles, non-healing lesions, Dryness, Color Changes)
Musculoskeletal (e.g., Muscles/Joint Pain, Stiffness, Back Pain, Joint Swelling)
Neurological (e.g., Dizziness, Fainting, Seizures, Weakness)
Psychiatric (e.g., Nervousness, Depression, Memory Loss, Stress)
Respiratory (e.g., Cough, Sputum, Shortness of Breath, Wheezing)
None
Medical History
Select All That Apply
Asthma
High Blood Pressure
Any Cancer
Cholesterol Problems
Depression
Diabetes
Emphysema
Hearth Problems
Kidney Disease
Liver Disease
Osteoporosis
Seizures
Strokes
Thyroid Problems
Surgery
Allergies (Seasonal)
Allergies to Medication
None
Allergies to Medications: Please List
All Current Medications
Please List with Dosage
Patient Eye History. Select all that apply
Blindness
Cataracts
Corneal Problems
Diabetic Retinopathy
Dry Eye
Eye Allergy
Eye Injury
Floaters/Spots
Light Flashes
Frequent Eye Infections/Styes
Glaucoma
Glaucoma Suspect
Iritis/Uveitis
Lazy/Crossed Eye
Macular Degeneration
Retinal Detachment/Tear
Other
None
Other: Please Specify
Has Patient's Family Experienced Any of These Medical Conditions? Select all that apply.
Blindness
Cataracts
Corneal Problems
Diabetic Retinopathy
Dry Eye
Eye Allergy
Eye Injury
Floaters/Spots
Light Flashes
Frequent Eye Infections/Styes
Glaucoma
Glaucoma Suspect
Iritis/Uveitis
Lazy/Crossed Eye
Macular Degeneration
Retinal Detachment/Tear
Other
None
Other: Please Specify
Any Patient Surgeries? Select all that apply.
Cataract
Corneal Transplant
Eye Muscle Surgery
Glaucoma Laser
Glaucoma Surgery
LASIK/PRK
Retinal Laser
Retinal Surgery
Retinal Injections
RK Incisions
Yag (Laser After Cataract)
Other
None
Other: Please Specify
Has Patient's Family Undergone Any of The Procedures below? Select all that apply.
Cataract
Corneal Transplant
Eye Muscle Surgery
Glaucoma Laser
Glaucoma Surgery
LASIK/PRK
Retinal Laser
Retinal Surgery
Retinal Injections
RK Incisions
Yag (Laser After Cataract)
Other
None
Other: Please Specify
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