Bonds Eye Care Patient Registration

Patient Information and Medical History Form
Thank you for using our secure online forms. Please fill out as much information as you can. When you are finished be sure to hit the submit button at the bottom of the form. If you have any questions, please call us at 610-269-3177. We can always change the data in the office if you are unsure about what to enter in any of the fields.
Patient Information
*required (first and last name and either a home OR cell phone)
Name*
Prefix First Middle Last Suffix
Nickname
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone*
Work Phone
Email*
Preferred Contact By
Date of Birth*
MM slash DD slash YYYY
Sex
- Male
- Female
Marital Status
Employement Status
- Employed
- FT Student
- PT Student
Occupation/Grade
Employer/School
Parent/Guardian
Race
Ethnicity
Preferred Language
Who may we thank for referring you to our office?
Insurance Information
Primary Insurance Company Name
Identification number
Insurance Company Phone Number
Insured's Name
Prefix First Middle Last Suffix
Insured's Date of Birth
MM slash DD slash YYYY
Patient's relationship to Insured
Do you have Secondary Insurance?
Ocular History
Who was your previous eye doctor?
When was your last eye exam?
Check the box for any conditions that apply:
Glaucoma
- You
- Mom
- Dad
- Sibling
Describe (type, when diagnosed, which eye(s), treatment,etc)
Macular Degeneration
- You
- Mom
- Dad
- Sibling
Describe (type, when diagnosed, which eye(s), treatment,etc)
Retinal problems
- You
- Mom
- Dad
- Sibling
Describe (type, when diagnosed, which eye(s), treatment,etc)
Cataracts
- You
- Mom
- Dad
- Sibling
Describe (type, when diagnosed, which eye(s), treatment,etc)
Lazy Eye/Eye Turn
- You
- Mom
- Dad
- Sibling
Describe (type, when diagnosed, which eye(s), treatment,etc)
List any other medical conditions you have had, including non-drug allergies:
List any other significant eye problems you have had:
List all prescription and over-the-counter medication you currently take. Include any supplements:
List all vision concerns you currently have:*
Examples are: blurred vision, headaches, eyestrain, double vision, or losing your place when reading, itching, burning, redness, pain, sensitivity to light, watering, crusting or mucus discharge, seeing rainbows around white lights at night, flashes of light or dark spots/squiggles/webs
How many hours/day do you typically spend using a computer or other digital devices?
If you are having complaints with computer work, how far is the monitor from your eyes?
How many hours/day do you typically spend reading books, magazines, etc?
What are your hobbies/sports activities?
Do you have sunglasses?
Do you have back-up glasses?
Are you interested in contacts?
Contact Lens Wearers Only
What disinfecting solution do you use?
How long do you usually wear your lenses?
How often do you replace your lenses?
How old is your current pair of contacts?
Soreness or Irritation:
Burning or Watering:
Eye Fatigue:
Do you use eye drops?
Symptoms (Yes/No)
General Medical History
List ALL major injuries or surgeries you have had and approx dates:
List any drug allergies you have:
Primary physician's name and phone
When was your last physical exam?
Check the box for any conditions that apply:
Hypertension
- You
- Mom
- Dad
- Sibling
Describe (type, when were you diagnosed, etc)
Thyroid
- You
- Mom
- Dad
- Sibling
Describe (type, when were you diagnosed, etc)
Cardiovascular
- You
- Mom
- Dad
- Sibling
Describe (type, when were you diagnosed, etc)
Cancer
- You
- Mom
- Dad
- Sibling
Describe (type, when were you diagnosed, etc)
Diabetes
- You
- Mom
- Dad
- Sibling
Describe (type, when were you diagnosed, etc)
If YOU are diabetic, when were you diagnosed?
Last A1C level?
Are you Pregnant or Nursing?
Smoking Status
Alcohol Use
Do you live alone?
Review of Systems
Have you been diagnosed with any of the following?
- HIV/AIDS
- Hepatitis
- Tuberculosis
- Any other infectious disease
Describe
General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain)
- Yes
- No
Describe
Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, sleep apnea, hearing problems)
- Yes
- No
Describe
Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs)
- Yes
- No
Describe
Respiratory (e.g., chronic cough, shortness of breath, wheezing)
- Yes
- No
Describe
Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge, menstrual changes, impotence)
- Yes
- No
Describe
Gastrointestinal (e.g., constipation, diarrhea, gastric reflux (GERD), jaundice, nausea, vomiting)
- Yes
- No
Describe
Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination)
- Yes
- No
Describe
Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements)
- Yes
- No
Describe
Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration)
- Yes
- No
Describe
Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, dementia, speech problems)
- Yes
- No
Describe
Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive)
- Yes
- No
Describe
Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising)
- Yes
- No
Describe
Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes)
- Yes
- No
Describe
You're Done! Please hit the Submit button below.

Bonds Eye Care Patient Registration

Patient Information and Medical History Form

Patient Information

Insurance Information

Ocular History

Check the box for any conditions that apply:

Contact Lens Wearers Only

General Medical History

Check the box for any conditions that apply:

Review of Systems

You're Done! Please hit the Submit button below.