Skip to content
Search for:
Optimal Vision Health
admin
2018-06-07T21:11:59+00:00
Optimal Vision Health
Step
1
of
2
50%
Patient Registration
Title
Mr.
Ms.
Miss
Mrs.
Dr.
Other
Please specify
Name
*
First
Last
Nickname
Date of Birth
*
MM slash DD slash YYYY
Age
Sex
Male
Female
Marital Status
Single
Married
Divorced
Widowed
Home Phone (or Cell if no home)
*
Cell Phone
Work Phone
Social Security Number
XXX-XX-XXXX
Email
*
Do You Wear Contacts?
*
Yes
No
Would You Like Text Reminders?
Yes
No
Family Physician Phone Number
Emergency Contact
Mr.
Mrs.
Miss
Ms.
Dr.
Prefix
First
Last
Home Phone
Cell Phone
Emergency Contact's Relationship to Patient
How Did You Hear about Us?
Insurance
Web Search
Facebook
Yelp
Yahoo
Google
Friend
Other
Name
First
Last
Other: Please Specify
Employment Information
Occupation
Status
Full-time
Part-time
Retired
Not Employed
Employer
Vision Insurance Information
Do you have vision insurance?
Yes
No
(1st) Primary Insurance
Subscriber's Name
First
Last
ID Number
Plan Number
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 Insurance Information
Do you have medical insurance?
Yes
No
(1st) Primary Insurance
ID Number
Subscriber's Name
First
Last
Plan Number
Subscriber's SSN
Subscriber's Birth Date
MM slash DD slash YYYY
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
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
List all medications, including over-the-counter
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
Concussion/Head Injury
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 Experienced Any of These Medical Conditions? Select all that apply.
Blindness
Cataracts
Keratoconus
Diabetic Retinopathy
Glaucoma
Lazy/Crossed Eye
Macular Degeneration
Retinal Detachment/Tear
Other
None
Other: Please Specify
Signature
Go to Top
