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The Eye Works – Registration Forms
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2017-10-18T19:00:08+00:00
The Eye Works - Med Questionaire
Welcome to The Eye Works Optometry - Dr. Craig Sultan
Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
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
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Phone (Home)
Phone (Work)
Phone (Cell)
Email
Date Of Birth
Occupation
Parent / Guardian
Marital Status: S/M/D/W
Name of Vision Insurance
Major Medical Ins.
Subscriber Name
DOB
SS#
What is the best way to contact you?
Phone
E-mail
Text Message
Mail
Pigeon
Smoke Signals
How did you hear about our office?
Major reason(s) for today's visit (Select all that apply)
Glasses
Contacts
Laser Correction
Eye Health
General Wellness
Other (Please explain)
Last vision exam & location
Currently wear contact lenses? Yes or no. If yes, any concerns?
Interested in the newest in contacts?
Number of hours per day on computer or electronic devices
Number of hours per day spent outdoors
Do you have prescription sunglasses?
Do you drive at night?
Interested in laser correction?
Do you experience, or have you had any of the following? With current correction
Blurry vision - distance or near
Fluctuating vision
Eye pain or soreness
Eyestrain
Chronic dryness
Burning eyes
Eyes tear or water
Eye discharge
Scratchy, gritty, sandy feeling
Floaters/spots
Flashes of light
Headaches/Migraines
Trouble with night vision
Eye infections recently
Eye injury/Trauma
Glare at night
Sun sensitivity
Double vision
Macular degeneration
Cataracts
Glaucoma
Crossed or wandering eye
Lazy eye
Iritis/Uveitis
Retinal detachment/Tear
Eye surgery
Personal Medical History (Click all that apply)
High blood pressure
Cholesterol
Diabetes
Thyroid Hi/Low
Neurological disease
Arthritis
Depression/Anxiety
Lyme disease
Allergies
Head trauma
Kidney disease
Weight gain/loss
Ocular herpes
Cancer - Type
Family History
Diabetes - Who?
Glaucoma
Macular degeneration
High blood pressure
Blindness
Stroke
List all current meds
Last med exam
Physician's name
Additional comments
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Date