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3504 McPherson Eye Care – Established Patient Registration Form
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2020-07-17T20:08:35+00:00
3504 McPherson Eye Care - Established Patient Registration Form
Welcome Back!
We believe your success starts with your vision. Thank you for listing any updates since we last saw you!
Name
*
First
Last
Preferred name
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home phone
Work phone
Cell phone
Email
Date of birth
*
MM slash DD slash YYYY
Occupation
Employer
Medical insurance company
Member ID/ Policy number
Group number
Policy holder's name (if different)
First
Last
Policy holder date of birth
MM slash DD slash YYYY
Policy holder social security number (Last 4)
Relationship to patient
Vision insurance/Plan company
Member number
Policy holder's name (if different)
First
Last
Policy holder date of birth
MM slash DD slash YYYY
Policy holder social security number (Last 4)
Relationship to patient
Name of primary care provider
Pharmacy name and location
Are you currently experiencing? (Check all that apply)
Blurry Distance Vision
Blurry Near Vision
Burning
Double Vision
Dryness
Eye Strain
Fainting or Dizziness
Flashes of Light
Glare or reflection
Gritty Feeling
Headaches
Itchiness
Nausea
Objects Floating in Vision
Redness
Sensitivity to Light
Sudden Loss of Vision
Trouble Seeing at Night
Uncomfortable Eyewear
Watery Eyes
Other
Other
Name of previous doctor if not at McPherson Eye Care
First
Last
When was your last eye exam? (Approximately)
Never
Less than one year
2-3 years
3-4 years
More than 5 years
Do you wear eyeglasses?
Yes
No
When did you get them? (Approximately)
Less than one year
2-3 years
3-4 years
More than 5 years
Do you wear contact lenses?
Yes
No
What brand are the contact lenses?(if known)
How often do you replace your contact lenses?
Daily
2 Weeks
Monthly
Do you experience dryness?
Yes
No
What brand of solution do you use?
Biotrue
Clear Care
Generic
Opti-free
Revitalens
Patient eye health
Do you have or have you had any of the conditions below?
Amblyopia (Lazy Eye)
Cataracts
Color Vision Deficiency
Diabetic Retinopathy
Drooping Eyelid
Dry Eyes
Eye Turn
Glaucoma
Infection of Eye/Lid
Loss of Vision-Central
Loss of Vision-Side
Macular Degeneration
Retinal Detachment
None of the above
List all past eye surgeries (please include approximate date and surgeon if known)
List all eye medications you currently use (include over the counter, contact lens drops and dosages)
Patient general heatlh
Please select all that apply to you.
Allergies
Asthma/Respiratory
Blood Disorders
Cancer
Hypertension (High Blood Pressure)
Chronic Bronchitis
Chronic Cough
Diabetes
Emphysema
Gastrointestinal Problems
Heart Attack
Heart Disease
Stroke
Headaches/Migraines
Kidney Disorders
Psychiatric/Depression
Rheumatoid Arthritis
Thyroid Disorder
Tuberculosis
Weight Loss/Gain
None of the above
(Women) Are you Pregnant?
Yes
No
Due date
(Women) Are you breastfeeding?
Yes
No
List surgeries you have had in the last 10 years
Current medications and dose (include over the counter and supplements)
Family history (includes parents, grandparents, siblings, children; living or deceased)
Arthritis
Blindness
Cancer
Cataract
Diabetes
Glaucoma
Heart Disease
High Blood Pressure
Kidney Disease
Macular Degeneration
Retinal Detachment/Disease
Stroke
Thyroid Disease
None of the Above
Social history
Do you use Tobacco Products?
Current
Previous
Never
Do you drink Alcohol?
Socially
Daily
Never
Please bring your:
- Insurance cards
- Glasses, sunglasses, readers and computer/hobby glasses
- Contact lens prescription, boxes or foil packs
Thank you!
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