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Vision Care Associates Patient Registration Form
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2017-07-06T01:14:25+00:00
Welcome to Vision Care Associates. Thank you for choosing us for your eyecare needs. We are delighted to have you as a patient and appreciate the confidence you placed in us. Please take a moment to complete the following information.
Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Middle
Last
Gender
*
Male
Female
Preferred Name
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Social Security Number
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Email
*
Home Phone
*
Cell Phone
*
Day Phone
Preferred phone number
*
Home Phone
Cell Phone
Day Phone
Emergency Contact
*
First
Last
What is their relationship with you?
*
Emergency Phone
*
Race
*
American Indian or Alaska Native
Asian
Black or African American
White
Caucasian
Native Hawaiian or Other Pacific Islander
Native American
Other Race
Refuse to Specify
Unknown
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Unknown
Preferred Language
*
Height
*
Weight
*
How were you referred to our office?
*
Primary Care Physician and Clinic Name
*
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone Number
*
Fax Number
Current Medications
*
Allergies
*
What is the reason for today's visit?
*
When was your last eye exam?
*
Do you currently wear glasses or contacts?
*
Yes
No
If contacts, what brand?
Are you happy with your current brand of contacts?
Do any of the following apply to you?
*
Glaucoma
Cataract
Macular Degeneration
Retinal Detachment
Color Blindness
Headaches
Glare/Light Sensitivity
Lazy Eye
Dryness
Excess Tearing
Itching
Redness
Floaters
Sandy/Gritty Feeling
Mucous Discharge
Double Vision
Loss of Vision
Drooping Eyelid
Flashes
Blurred Vision
Burning
Eye Pain
None of the above
Do you currently smoke?
*
Yes
No
If yes, how much/often?
If you are not a current smoker have you previously smoked?
Yes
No
When did you quit?
Do you chew tobacco?
*
Yes
No
If yes, how often?
Do you drink?
*
Yes
No
If yes, how often?
Do you use illegal drugs?
*
Yes
No
Do you engage in regular exercise?
*
Yes
No
Do you take nutritional supplements (vitamins)?
*
Yes
No
Do any of the following apply to you?
*
Weight Loss
Ear Nose Throat
Respiratory
Gastrointestinal
Kidney
Muscles, Bones, Joints
Anxiety, Depression
Thyroid, Diabetes
Blood/Lymph
Allergies
None of the above
Please explain the issues
*
Past illness or injuries
*
Past Surgeries
*
Current Occupation
*
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