Patient Registration Form Name First Middle Last Preferred Name:Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell Phone:Home Phone:Daytime Phone:Email Preferred communication Phone Email Mail Date of Birth MM slash DD slash YYYY Sex Male Female SSNMarital Status:RacePreferred Language:Ethnicity Hispanic or Latino Native Hawaiian Not Hispanic or Latino Decline Occupation:Employer:How did you hear about us?Referred By:MEDICAL INFORMATIONWhat is your general health? Fair Good Excellent Do you have any problems with any of the follow systems? Eyes Ears Nose Throat Lungs Respiratory System Skin Kidneys Nervous System Thyroid Gland Blood Allergies Mental Health Medical Conditions (Ex: Hypertension, Thyroid, Etc):Diabetes: Yes No Date of Diabetes Diagnosis:Last A1c:Last BS:Current Medications:Medication Allergies:Other Allergies: Yes No Other Allergies: Seasonal Year Round Headaches: Yes No How often?Operations:Do you smoke: Yes No Family Physician:Date of Last Visit to Family Dr:PERSONAL EYE INFORMATIONLast eye exam:Current/Previous eye doctor:Single Vision, Progressive, Bifocal?Do you have glaucoma? Yes No Do you have cataracts? Yes No Do you wear eyeglasses? Yes No Do you have cataracts? Yes No Have you ever had any eye operations: Yes No Type? When?Do you have dry eyes or watery eyes? Yes No Do you have blurred Vision? Yes No Do you have blurred Vision? Yes No Do you wear contact lenses? Yes No BrandDo you sleep in your contacts:How often do you replace your contacts:Do you sleep in your contacts:Any additional Eye Problems or concerns?FAMILY HISTORYHigh Blood Pressure: Yes No Who had problem:Diabetes: Yes No Who had problem:Glaucoma: Yes No Who had problem:Macular Degeneration: Yes No Who had problem:Retinal Detachment: Yes No Who had problem:Cataracts: Yes No Who had problem:Other Eye Condition: Yes No Who had problem:Patient/Guarantor SignatureDate MM slash DD slash YYYY Δ
