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Simpson and Mann Optometry Adult Registration
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2018-10-19T19:40:44+00:00
Simpson and Mann Adult Registration Form
Today's Date
MM slash DD slash YYYY
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone
Cell Phone
Social Security Number
Driver's License Number
Employer
Work Phone
Person responsible for account
First
Last
Date of Last Eye Exam
MM slash DD slash YYYY
Have you ever had vision therapy?
Yes
No
Have you ever worn glasses?
Yes
No
Do you wear glasses now?
Yes
No
Why do you wear glasses?
For distance only
For near only
Wear them full time
For computer moniter
For sports
Do you wear contacts now?
Yes
No
What contacts do you wear?
Have you had problems wearing contacts?
Yes
No
What problems have you had wearing contacts?
Have you been told you cannot wear contacts?
Yes
No
Are you interested in trying contacts?
Yes
No
Health History
Allergies
Respiratory Disease
Cancer
Diabetes
Drug sensitive
Elevated cholesterol
Heart problem
High blood pressure
Thyroid
Migraine or headaches
Head trauma
Lazy eye
Turned eye
Color "blind"
Light sensitive
Eye strain
Dry eyes
Floaters/spots
Flashing lights
Retinal detachment
Blindness
Cataracts
Glaucoma
Eye surgery or injury
Check all that apply to you
Health History
Allergies
Respiratory Disease
Cancer
Diabetes
Drug sensitive
Elevated cholesterol
Heart problem
High blood pressure
Thyroid
Migraine or headaches
Head trauma
Lazy eye
Turned eye
Color "blind"
Light sensitive
Eye strain
Dry eyes
Floaters/spots
Flashing lights
Retinal detachment
Blindness
Cataracts
Glaucoma
Check all that run in your family
Are you currently under a physician's care?
Yes
No
Doctor's Name
First
Last
Date of last physical exam
MM slash DD slash YYYY
Are you regularly taking medications?
Yes
No
For what conditions?
How is your general health?
Excellent
Good
Fair
Poor
What kind of work do you do?
What activities do you do at work?
Driving
Typing
Data entry
Computers
Program inspecting
Account
Writing/ editing
Using spreadsheets
Loading
Deliveries
Sales
Monitor instruments
Other activities
What other activities do you do at work?
Do you use a computer at work?
Yes
No
Do you use a computer at home?
Yes
No
How many hours do you spend on the computer daily?
What lenses do you use while on the computer?
None
Glasses
Bifocals
Contacts
When computing, do your eyes get
Red
Dry
Ache
Sore
None
Do you feel pain or discomfort in you
Neck
Back
Shoulders
None
Do letters ever seem to "swim"?
Yes
No
Does office lighting ever bother you?
Yes
No
Do reflections and glare bother you?
Yes
No
Do you experience any of the following at work or at home?
Headaches
Letters blur as you read
Occasionally see double
Eyestrain
Eyes red or watery
Pulling sensation near eyes
Get sleepy
Lose your place often
Avoid certain tasks
Increased effort to see clearly as day goes on
Blurred street signs on way home from work
Difficulty bringing print or objects into focus
In what recreational activities do you participate?
Read
Racquetball
Tennis
Golf
Baseball
Basketball
Swim
Camp
Sew
Play cards
Flying
Video games
Musical instrument
Other activities
What other recreational activities?
Do you wear any special or protective eyewear for your sport?
Yes
No
Does your vision, or do you lenses, interfere with any activities?
Yes
No
What are you doing to protect your eyes from ultraviolet exposure?
Do you currently wear glasses that have an anti-reflective coating?
Yes
No
Is television viewing ever uncomfortable?
Yes
No
Describe discomfort
Do you recline while viewing television?
Yes
No
Do your lenses work for TV?
Yes
No
Third Choice
Do you often play video games?
Yes
No
Hours spent playing video games daily
Are you a new patient?
Yes
No
How did you hear about us?
Friend/relative
Another Dr.
Yellow pages
Online
Who referred you?
Where online did you hear about us?
PAYMENT TERMS: We are happy to assist you in the filing of your insurance claim. If your insurance will not pay the anticipated amount, or your insurance pays you directly, we ask that you pay the balance. Office policy calls for payment at the time of service. If eyewear or contact lenses are to be ordered, a minimum 50% deposit is requested and the balance is due upon delivery. We accept cash, personal checks, Visa and Mastercard. A monthly rebilling fee of $5 is added to all accounts with unpaid balances after 30 days. I have read and agree to all the provisions of the office financial policy I have received/reviewed a copy of the health care information privacy policy for Simpson and Mann Optometry
Signature
Date
MM slash DD slash YYYY
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