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Gilbert Eyecare Norfolk
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2018-02-23T01:23:29+00:00
Gilbert Eyecare Norfolk
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Patient Registration
Name
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Address
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State
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ZIP
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Date of Birth
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MM slash DD slash YYYY
Age
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Sex
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Male
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Marital Status
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Home Phone (or Cell if no home)
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Cell Phone
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Social Security Number
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XXX-XX-XXXX
Email
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Do You Wear Contacts?
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Would You Like Text Reminders?
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No
Family Physician Phone Number
Emergency Contact
Mr.
Mrs.
Miss
Ms.
Dr.
Prefix
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Home Phone
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Emergency Contact's Relationship to Patient
How Did You Hear about Us?
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Name
First
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Other: Please Specify
Employment Information
Occupation
Status
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Employer
Employer Phone
Vision Insurance Information
(1st) Primary Insurance
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ID Number
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Subscriber's Name
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First
Last
Subscriber's Birth Date
*
MM slash DD slash YYYY
Patient's Relationship to Subsriber
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Self
Spouse
Child
Other
Other: Please Specify
Medical Insurance Information
(1st) Primary Insurance
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ID Number
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Subscriber's Name
*
First
Last
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
Signature
If for any reason you need to cancel or reschedule you appointment, please do so 48 hours in advance to avoid a $50 late cancel/no show charge. If you have questions concerning our COVID Policies, please refer to our website.
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