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Bonds Eye Care Patient Registration
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2019-05-20T21:08:17+00:00
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
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Middle
Last
Suffix
Nickname
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
*
Cell Phone
*
Work Phone
Email
*
Preferred Contact By
Cell Phone
Home Phone
Work Phone
Other Phone
Text Message
Email
Date of Birth
*
MM slash DD slash YYYY
Sex
Male
Female
Marital Status
Single
Divorced
Married
Widowed
Employement Status
Employed
FT Student
PT Student
Occupation/Grade
Employer/School
Parent/Guardian
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other Race
Patient Declined to Specify
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Unknown
Patient Declined to Specify
Preferred Language
English
Spanish
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
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
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:
0
1
2
3
4
Other
Burning or Watering:
0
1
2
3
4
Other
Eye Fatigue:
0
1
2
3
4
Other
Do you use eye drops?
Yes
No
Other
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?
No
Unsure
Pregnant
Nursing
Smoking Status
Never smoker (<100 lifetime cigarettes or equialent quantity of cigar or pipe smoke)
Former smoker (no longer smokes)
Current some day smoker (not daily)
Light smoker (<10 cigs/day)
Heavy smoker (>10 cigs/day)
Smoker (current status unknown)
Unknown if ever smoked
Other
Alcohol Use
No
Yes
Occasionally
Socially
1 drink per day
Multiple drinks per day
Do you live alone?
No
Yes
Assisted Living
Nursing Home
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.
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