Heritage Valley Eye Care – Patient Registration Forms

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Heritage Valley Eye Careadmin2017-07-06T01:14:21+00:00

Heritage Valley Eye Care

Patient Registration Form

Health Questionnaire
Name
First Last
SSN
Date of Birth
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Primary Doctor
Pharmacy
Ethnicity
- Hispanic/Latino
- Not Hispanic/Latino
Race
- American Indian
- Alaska Native
- Asian
- African American
- Native Hawaiian/Pacific Islander
- White
- Other
What is your reason for your visit?
Personal Ocular History
Are you NOW experiencing any of the following? Please check all that apply.
- Flashes
- Floaters
- Tearing
- Double Vision
- Loss of Vision
- Loss of Sharpness
- Headaches
- Light Sensitivity
- Pain
- Red
- Burning
- Itching
- NONE OF THE ABOVE
In the PAST, have you had any of the following problems with your eyes? Please check all that apply.
- Glaucoma
- Cataract
- Injury
- Surgery
- Lazy Eye
- Crossed Eyes
- Dry Eye
- Nystagmus
- Age Related Macular Degeneration
- Inflammatory Disorder
- Retinal Hole
- Retinal Degeneration
- Keratoconus
- Patching
- Strabismus
- Nystagmus
- Amblyopia
- NONE OF THE ABOVE
Social History
Any use of alcohol?
- Yes
- No
If YES, amount:
How often?
- Daily
- Weekly
- Monthly
Any current tobacco use?
- Yes
- No
If YES, how many daily?
Previous Smoker?
- Yes
- No
Employer
Occupation
Student/Grade
Hobbies
Family Medical / Ocular History
Do any of these Medical condition(s) run in your family? Please check all that apply and identify family member.
Cancer
- Yes
- No
If YES, who of the following?*
- Mother
- Father
- Brother
- Sister
Diabetes*
- Yes
- No
If YES, who of the following?*
- Mother
- Father
- Brother
- Sister
High Blood Pressure*
- Yes
- No
If YES, who of the following?*
- Mother
- Father
- Brother
- Sister
Do any of the eye condition(s) listed run in your family? Please check all that apply and identify family member.
Cataracts*
- Yes
- No
If YES, who of the following?*
- Mother
- Father
- Brother
- Sister
Macular Degeneration*
- Yes
- No
If YES, who of the following?*
- Mother
- Father
- Brother
- Sister
Glaucoma*
- Yes
- No
If YES, who of the following?*
- Mother
- Father
- Brother
- Sister
Personal Medical Health
General Health*
- Developmental Disabilities
- Fatigue Syndrome
- Cancer
- None of the Above
Ear, Nose, Throat*
- Hearing Loss
- Dry Mouth
- Sinusitis
- Laryngitis
- None of the Above
Neurological*
- Stroke/CVA
- Tumor
- Migraine
- Multiple Sclerosis
- Cerebral Palsy
- Epilepsy
- None of the Above
Psychological*
- Depression
- Attention Deficit
- Anxiety
- Bipolar
- None of the Above
Cardiovascular*
- High Blood Pressure
- Stroke/CVA
- Heart Disease
- Vascular Disease
- Heart Failure
- None of the Above
Respiratory*
- Bronchitis
- Emphysema
- Asthma
- Sleep Apnea
- Smoker
- Chronic Obstruction
- None of the Above
Allergic/Immunologic*
- Drug Allergy
- Lupus
- Environment Allergies
- Rheumatoid Arthritis
- Sjogren's Syndrome
- None of the Above
Gastrointestinal*
- Crohn's
- Colitis
- Ulcer
- Acid Reflux
- Celiac Disease
- None of the Above
Genitourinary*
- Kidney Disease
- Prostate Disease/Cancer
- Pregnant
- Nursing
- STD-Herpetic/Chlamydia
- Herpes
- None of the Above
Musculoskeletal*
- Osteoarthritis
- Gout
- Arthritis
- Ankylosing Spondylitis
- Fibromyalgia
- Osteoporosis
- Muscular Dystrophy
- None of the Above
Integument (Skin)*
- Eczema
- Rosacea
- Psoriasis
- Herpes Simplex/Cold Sores
- Zoster/Shingles
- None of the Above
Endocrine (Hormone)*
- Type 2 Diabetes
- Thyroid
- Type 1 Diabetes
- Hormone Dysfunction
- None of the Above
Blood/Lymphatic*
- Cholesterol
- Anemia
- Ulcer
- Large Volume Blood Loss
- None of the Above
Please list below any medications/supplements that you are currently taking, and why.
Do you have any allergies to any medications? Please List:
Do you have any other allergies? (ex. dust, pollen, food, ragweed, hayfever, bees, etc.). Please List:
Latex Sensitivity*
- Yes
- No

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