LENTZ EYE CARE – WEST WICHITA – Patient Registration Forms

LENTZ EYE CARE - WEST WICHITA

Today’s Date
MM slash DD slash YYYY
HOW DID YOU DECIDE TO COME TO OUR PRACTICE?
Referral (by whom)
Sign/Location
Other.
Name
Prefix First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Patient Home Phone:
Patient Cell Phone:
Patient Age:
Untitled
- Male
- Female
Patient Date of Birth:
MM slash DD slash YYYY
Patient Email Address:
*We abide by all HIPPA privacy regulations and do not sell or market your demographic information, including your e-mail address, to anyone.
Patient Employer:
Employer Phone:
Name of Spouse:
First Last
Spouse Employer:
Patient SS#:
Person Responsible for Payment:
First Last
IF PATIENT IS A CHILD:
- Yes
- No
Father’s Name:
First Last
Father’s SS#:
Father’s Cell Phone:
Father’s Employer:
Mother’s Name:
First Last
Mother’s SS#:
Mother’s Cell Phone:
Mother’s Employer:
Medical Doctor Phone:
Name of Medical Doctor:
First Last
Date of Last Eye Exam:
MM slash DD slash YYYY
Last Eye Dr Seen:
First Last
Date of Last Medical Exam:
MM slash DD slash YYYY
Reason for leaving previous office:
INSURANCE INFORMATION
Insurance Company:
Policyholder’s Name:
First Last
Policyholder’s ID#:
Group #:
Policyholder’s DOB:
MM slash DD slash YYYY
Policyholder’s SS#:
I would like to discuss/learn more about:
- Glasses
- Sunglasses
- Contact Lenses
- Laser Refractive Surgery
Hobbies:
Financial Assignment Information: I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will immediately due and payable to Lentz Eye Care.
Initial
Date:
MM slash DD slash YYYY
MEDICAL HISTORY
Do you have any allergies to medications?
- No
- Yes
If yes, please Explain:
List any medications you take (including all oral medications, eye drops, oral contraceptives, aspirin, over the counter medications and home remedies):
List all major injuries, surgeries and/or hospitalizations you have had:
List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections or eye injury:
Are you pregnant and/or nursing?
- Yes
- No
Do you wear glasses?
- Yes
- No
If yes, how old is your present pair of lenses?
Do you wear contact lenses?
- Yes
- No
If yes, how old is your present pair of contacts?
Type of contact lenses:
- Rigid
- Soft
- Disposable
- Other
Are they comfortable?
- Yes
- No
FAMILY HISTORY

Please note any personal or family history (parents, grandparents, siblings, children, living or deceased) for the following conditions.
Blindness
- Self
- Family
WHOM
Cataract
- Self
- Family
WHOM
Crossed Eyes
- Self
- Family
WHOM
Glaucoma
- Self
- Family
WHOM
Macular Degeneration
- Self
- Family
WHOM
Retinal Detachment/Disease
- Self
- Family
WHOM
Arthritis
- Self
- Family
WHOM
Cancer
- Self
- Family
WHOM
Diabetes
- Self
- Family
WHOM
Heart Disease
- Self
- Family
WHOM
High Blood Presure
- Self
- Family
WHOM
Kidney Disease
- Self
- Family
WHOM
Lupus
- Self
- Family
WHOM
Thyroid Disease
- Self
- Family
WHOM
Multiple Sclerosis
- Self
- Family
WHOM
Other
- Self
- Family
If other, explain.
SOCIAL HISTORY
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
- Yes, I would prefer to discuss my Social History information directly with my doctor.
Do you drive?
- No
- Yes
If yes, do you have visual difficulty when driving?
- No
- Yes
If yes, please describe:
Do you use tobacco products?
- No
- Yes
If yes, type/amount/how long:
Do you drink alcohol?
- No
- Yes
If yes, type/amount/how long:
Do you use illegal drugs?
- No
- Yes
If yes, type/amount/how long:
Have you ever been exposed to or infected with
- Gonorrhea
- Hepatitis
- HIV
- Syphilis
REVIEW OF SYSTEMS

Do you currently, or have you ever had any problems in the following areas:

CONSTITUTIONAL
Fever, Weight Loss/Gain
- No
- Yes
- ?
INTEGUMENTARY (Skin)
- No
- Yes
- ?
NEUROLOGICAL
Headaches
- No
- Yes
- ?
Migraines
- No
- Yes
- ?
Seizures
- No
- Yes
- ?
EYES
Loss of Vision
- No
- Yes
- ?
Blurred Vision
- No
- Yes
- ?
Distorted Vision/Halos
- No
- Yes
- ?
Loss of Side Vision
- No
- Yes
- ?
Double Vision
- No
- Yes
- ?
Dryness
- No
- Yes
- ?
Mucous Discharge
- No
- Yes
- ?
Redness
- No
- Yes
- ?
Sandy or Gritty Feeling
- No
- Yes
- ?
Itching
- No
- Yes
- ?
Burning
- No
- Yes
- ?
Foreign Body Sensation
- No
- Yes
- ?
Excess Tearing/Watering
- No
- Yes
- ?
Glare/Light Sensitivity
- No
- Yes
- ?
Chronic Infection of Eye or Lid
- No
- Yes
- ?
Sites or Chalazion
- No
- Yes
- ?
Flashes/Floaters in Vision
- No
- Yes
- ?
Tired Eyes
- No
- Yes
- ?
ENDOCRINE
Thyroid/Other Glands
- No
- Yes
- ?
EARS, NOSE, MOUTH, THROAT
Allergies/Hay Fever
- No
- Yes
- ?
Sinus Congestion
- No
- Yes
- ?
Runny Nose
- No
- Yes
- ?
Post-Nasal Drip
- No
- Yes
- ?
Chronic Cough
- No
- Yes
- ?
Dry Throat/Mouth
- No
- Yes
- ?
RESPIRATORY
Asthma
- No
- Yes
- ?
Chronic Bronchitis
- No
- Yes
- ?
Emphysema
- No
- Yes
- ?
VASCULAR/CARDIOVASCULAR
Diabetes
- No
- Yes
- ?
Heart Pain
- No
- Yes
- ?
High Blood Pressure
- No
- Yes
- ?
Vascular Disease
- No
- Yes
- ?
GASTROINTESTINAL
Constipation
- No
- Yes
- ?
Diarrhea
- No
- Yes
- ?
GENITOURINARY
Genital/Kidney/Bladder
- No
- Yes
- ?
BONES/JOINT/MUSCLES
Rheumatoid Arthritis
- No
- Yes
- ?
Muscle Pain
- No
- Yes
- ?
Joint Pain
- No
- Yes
- ?
LYMPHATIC/HEMATOLOGIC
Anemia
- No
- Yes
- ?
Bleeding Problems
- No
- Yes
- ?
ALLERGIC/IMMUNOLOGIC
- No
- Yes
- ?
PHYCHIATRIC
- No
- Yes
- ?
PHYCHIATRIC
- No
- Yes
- ?
If you answered YES to any of the above or have a condition not listed, please explain & list medications:
Patient's Signature