Calhoun Vision – Patient Registration Forms

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Calhoun Visionadmin2017-07-06T01:14:30+00:00

Calhoun Vision Patient Intake Form

General/Demographic Information
Date
MM slash DD slash YYYY
Name*
Last Middle Initial First
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Cell Phone
Email*
OK to email/text reminders?
- Yes
- No
Gender:
- Male
- Female
Birth Date*
MM slash DD slash YYYY
Social Security Number
Marital Status
Employer
Occupation
Referred by:
Vision Information
Reason for Visit
- Yearly Exam
- Contact Lens Evaluation
Concerns about how you see?
- Near
- Far
- Computer
- Spots
- Flashes
- Other
Please specify 'Other'
Concerns about how your eyes feel?
- Itchy
- Watery
- Dry
- Red
- Headaches
- Fatigue
- Other
Please specify 'Other'
Do you wear glasses?*
- Yes
- No
Do you wear contacts?*
- Yes
- No
Have you had eye surgery?*
- Yes
- No
If yes, what for?
Medical History
Check All Conditions that apply to you.
Endocrine:
- Diabetes
- Thyroid Problem
- Other
- None
Please specify 'Other'

If you have a condition not listed, please describe it here.
Cardiovascular:
- Hypertension
- Heart Disease
- Other
- None
Please specify 'Other'

If you have a condition not listed, please describe it here.
Respiratory:
- Asthma
- COPD
- Other
- None
Please specify 'Other'

If you have a condition not listed, please describe it here.
Ocular:
- Glaucoma
- Macular Degeneration
- Other
- None
Please specify 'Other'

If you have a condition not listed, please describe it here.
Psychiatric:
- Depression
- Anxiety
- Other
- None
Please specify 'Other'

If you have a condition not listed, please describe it here.
Constitutional:
- Cancer
- Trauma/Blood Loss
- Other
- None
Please specify 'Other'

If you have a condition not listed, please describe it here.
Neurological:
- Multiple Sclerosis
- Epilepsy
- Other
- None
Please specify 'Other'

If you have a condition not listed, please describe it here.
Immunologic:
- AIDs or HIV
- Lupus
- Other
- None
Please specify 'Other'

If you have a condition not listed, please describe it here.
Musculoskeletal:
- Osteoarthritis
- Fibromyalgia
- Other
- None
Please specify 'Other'

If you have a condition not listed, please describe it here.
Hematological:
- Anemia
- Leukemia
- Other
- None
Hematological condition not listed?

If you have a condition not listed, please describe it here.
Dermatologic:
- Eczema
- Rosacea
- Other
- None
Dermatologic condition not listed?

If you have a condition not listed, please describe it here.
Ear/Nose/Throat:
- Hearing Loss
- Current Infection
- Other
- None
Ear/Nose/Throat condition not listed?

If you have a condition not listed, please describe it here.
Allergies:*

Please list your allergies. Drug, or environmental.
Please list any medications and/or drugs you are taking and what they are used for (including herbal):*
Smoking*
- Never
- Former Smoker
- Current - every day
- Current - some days
Family History: Has anyone in your family (grandparents, parents, siblings, or children) been diagnosed with:
- Retinal Detachment
- High Blood Pressure
- Diabetes
- Heart Disease
- Thyroid Disease
- Lupus
- Blindness
- Cataracts
- Glaucoma
- Macular Degeneration

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