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Optimal Vision Health
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2018-06-07T21:11:59+00:00
Optimal Vision Health
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Patient Registration
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Name
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Date Format: MM slash DD slash YYYY
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Email
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Do You Wear Contacts?
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Would You Like Text Reminders?
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Family Physician Phone Number
Emergency Contact
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Employment Information
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Vision Insurance Information
Do you have vision insurance?
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(1st) Primary Insurance
Subscriber's Name
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Subscriber's Birth Date
Date Format: MM slash DD slash YYYY
Subscriber's SSN
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Patient's Relationship to Subsriber
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Medical Insurance Information
Do you have medical insurance?
Yes
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(1st) Primary Insurance
ID Number
Subscriber's Name
First
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Plan Number
Subscriber's SSN
Subscriber's Birth Date
Date Format: MM slash DD slash YYYY
Patient's Relationship to Subsriber
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Medical Information
Patient/Guardian Name
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Last
Date of Birth
Date Format: 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
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