Registration

Patient Registration - Primary Eye Care

Preferred Provider & Office Location

Office Location
Preferred Provider David M. Blair, OD


Patient Information

Salutation
First Name
Middle Initial
Last Name
Suffix
Date of Birth
Social Security Number - -
Numbers only, no special characters
Street Address
City
State
Zip -
Country
Address Type
Home Phone - -
Cell Phone - -
Work Phone - -
Work Phone Extension
Email I do not have an email account
How would you prefer to be contacted by our office?
Gender
Race (defined as genealogy, shared history/culture)
Ethnicity (defined as shared biological or genetic traits and physical characteristics)
Primary Language
Nickname
Marital Status
Employer Name
Occupation
Who shall we contact in case of an emergency?
First Name
Last Name
Relationship
Home Phone - -
Work Phone - -
Cell Phone - -


Account Responsible Information

This section is for the person responsible for the account, usually the insurance subscriber.

Salutation
First Name
Middle Initial
Last Name
Suffix
Date of Birth
Social Security Number - -
Numbers only, no special characters
Street Address
City
State
Zip -
Primary Phone - -
Email
I do not have an email account
Patient Relationship


Medical Insurance Information

Please include your medical insurance
carrier. In the event you have a medical emergency (ex. Pink Eye), we will authorize your medical insurance.

Insurance Carrier Name
Carrier Street
Carrier City
Carrier State
Carrier Zip -
Insurance ID #
Group Number
Group Name
Salutation
Insured Person First Name
Middle Initial
Last Name
Suffix
Insured Date of Birth
Sex
Employer/ School
Phone Number - -
Relationship to Insured
Insured Street Address
City
State
Zip -
Insurance Carrier Name
Carrier Street
Carrier City
Carrier State
Carrier Zip -
Insurance ID #
Group Number
Group Name
Salutation
Insured Person First Name
Middle Initial
Last Name
Suffix
Insured Date of Birth
Sex
Employer/ School
Phone Number - -
Relationship to Insured
Insured Street Address
City
State
Zip -
Insurance Carrier Name

Carrier Street
Carrier City
Carrier State
Carrier Zip -
Insurance ID #
Group Number
Group Name
Salutation
Insured Person First Name
Middle Initial
Last Name
Suffix
Insured Date of Birth
Sex
Employer/ School
Phone Number - -
Relationship to Insured
Insured Street Address
City
State
Zip -


Vision Insurance Information

Please include your vision insurance carrier. For your comprehensive eye exam, we will authorize your vision insurance

Insurance Carrier Name

Carrier Street
Carrier City
Carrier State
Carrier Zip -
Insurance ID #
Group Number
Group Name
Salutation
Insured Person First Name
Middle Initial
Last Name
Suffix
Insured Date of Birth
Sex
Employer/ School
Phone Number - -
Relationship to Insured
Insured Street Address
City
State
Zip -


Referral Information

How did you hear about us?

Doctor Referral
Patient Referral
Internet Search

Other
Location
My Insurance Company
Television
Word of Mouth
Other:


Medications

Please list all of your current medications, including over the counter, herbals and supplements.

Medication Name Date Started (mm/dd/yyyy) Use









































Allergies

Name of Allergy Reaction Severity Onset Type











Surgeries

Date of Surgery (mm/dd/yyyy) Surgeon Name of Procedure





















General History

Who is your Primary Care Physician?
Last Eye Exam
Dr Last Eye Exam
Do you work on a computer? YesNo
Hours per day


Review of Systems

Constitution
Negative
Chills
Fatigue
Fever
Insomnia
Sleeping All The Time
Sudden Weight Gain
Sudden Weight Loss
Weakness
Other:
Ears, Nose, Throat
Negative
Chronic Colds
Chronic Sinusitis
Chronic Strep Infections
Dentures
Ear - Itching
Ear Infections
Ear Pain
Hearing Aid Both Ears
Hearing Aid Left Ear
Hearing Aid Right Ear
Hearing Loss Left Ear
Hearing Loss Right Ear
Mouth Sores
Nose Bleeds
Partial Hearing Loss Both Ears
Partial Hearing Loss Left Ear
Partial Hearing Loss Right Ear
Ringing In Ears
Runny Nose
Sinus Pain
Sinusitis
Sore Throat
Stuffy Nose
Other:
Neurological
Negative
Bell's Palsy
Cranial Nerve Palsy
Dizziness
Epilepsy
Involuntary Movement
Migraines
Paralysis
Seizures
Stroke
TIA
Vertigo
Other:
Psychiatric
Negative
Depression
Panic Episodes
Stress
Other:

Cardiovascular/ Heart
Negative
Angina
Arrhythmia
Bypass Graft
Bypass Surgery
Chest Pain
Congestive Heart Failure
Coronary Artery Disease
Cyanosis
Heart Disease
Heart Murmur
Heart Palpitation
High Blood Pressure Controlled
High Blood Pressure Uncontrolled
High Cholesterol
History Of Heart Disease
Irregular Heart Beat
Mitral Valve Prolapse
Pacemaker
Shortness Of Breath
Stent
Stroke
Valve Replacement
Other:
Respiratory/ Lungs
Negative
Asthma
Bronchitis
Chronic Bronchitis
Chronic Cough
Collapsed Lung Left
Collapsed Lung Right
COPD
Cough
Emphysema
Lung Cancer
Pleurisy
Pneumonia
Sarcoid
Shortness Of Breath
Tuberculosis
Other:
Stomach/ Intestines
Negative
Abdominal Pain
Bowel Cancer
Change In Appetite
Constipation
Crohn's Disease
Diarrhea
Difficulty Swallowing
Diverticulitis
Esophagitis
Frequency Of Bowel Movements
Gall Bladder Disease
Gastric Reflux
Heartburn
Hemorrhoids
Hepatitis Type A
Hepatitis Type B
Hepatitis Type C
Hernia
Indigestion
Irritable Bowel Syndrome
Jaundice
Nausea
Pancreatitis
Stomach Cancer
Ulcerative Colitis
Ulcers
Other:
Genitals/ Kidney/ Bladder
Negative
Bladder Infections
Bladder Repair
Bladder Spasms
Cervical Cancer
Changes In Color Of Urine
Dialysis
Endometriosis
Frequent Urination
Incontinence
Kidney Failure
Kidney Infections
Kidney Stones
Kidney Transplant
Menopause Symptoms
Ovarian Cancer
Ovarian Cysts
Prostate Cancer
Recurrent Urinary Tract Infections
Renal Cancer
Renal Stricture
Sexually Transmitted Disease
Testicular Cancer
Uterine Cancer
Uterine Fibroids
Other:
Bones/ Joints/ Muscles
Negative
Arthritis
Back Pain
Bone Cancer
Cerebral Palsy
Gout
Joint Pain
Juvenile Rheumatoid Arthritis
Limited Range Of Motion
Multiple Sclerosis
Muscle Pain
Muscular Dystrophy
Neck Pain
Polymyalgia
Rheumatoid Arthritis
Other:
Integumentary/ Skin
Negative
Basal Cell Carcinoma
Bruising
Changes In Color/ Pigmentation
Changes In Nails/ Hair
Dermatitis
Dryness
Eczema
Excessive Sweating
Itching
Lupus
Psoriasis
Skin Cancer
Skin Rash
Other:
Endocrine
Negative
Type 1 Diabetes - IDDM
Type 2 Diabetes - NIDDM
Gestational diabetes
Pre-diabetic
Adrenal Gland Disorders
Diabetes - Diet Controlled
Hyperthyroidism
Hypoglycemia
Hypothyroidism
Other:
Hematologic/ Lymphatic
Negative
Anemia
Blood Disorders
Enlarged Lymph Nodes
Hemachromatosis
Hemophilia
Leukemia
Lyme Disease
Lymphoma
Other:
Allergic/ Immunologic
Negative
Allergy Shots
HIV
Immune Disorder
Lupus
Seasonal Allergies
Other:
Other
Other:
Past Medical Conditions
Details of Past Medical Conditions


Social History

Do you smoke?
Do you drink alcohol?
Recreational Drug Use


Ocular History

Glaucoma
Negative
Glaucoma Suspect
Glaucoma Unspecified
Narrow Angle Glaucoma
Open Angle Glaucoma
Cataracts
Negative
Beginning Cataracts
Cataract Removed Both Eyes
Cataract Removed Left Eye
Cataract Removed Right Eye
Macular Degeneration
Negative
Macular Pucker (Epiretinal Membrane)
Previous Laser Treatment
Previous Treatment by Injection
Previously Diagnosed
Eye Injury
Negative
Corneal Foreign Body Left Eye
Corneal Foreign Body Right Eye
Eye Trauma
Penetrating Injury
Retinal Disease
Negative
Diabetic Retinopathy
Macular Degeneration
Macular Hole
Retinal Detachment
Retinal Tears
Other Eye Disease
Negative
Enucleation Both Eyes
Enucleation Left Eye
Enucleation Right Eye
Exophthalmos Both Eyes
Exophthalmos Left Eye
Exophthalmos Right Eye
Phthisis Bulbi Both Eyes
Phthisis Bulbi Left Eye
Phthisis Bulbi Right Eye
Blindness/ Vision Loss
Negative
Congenital
Corneal Scar
Enucleation
Injury Related
Legally Blind
Strabismus
Negative
Esophoria
Esotropia
Exophoria
Exotropia
Muscle Surgery
Amblyopia
Negative
Both Eyes
One Eye
Treatment Management: Eye Muscle Surgery
Treatment Management: Glasses
Treatment Management: Patching
Treatment Management: Pharmacological
Treatment Management: Vision Therapy
Ocular Complications Related to Diabetes YesNo
Dry Eye
Negative
Mild
Moderate
Severe
Other:


Family History

Family History of Glaucoma Mother Father Sibling Paternal Grandmother Maternal Grandmother Paternal Grandfather Maternal Grandfather Other
Cataracts Mother Father Sibling Paternal Grandmother Maternal Grandmother Paternal Grandfather Maternal Grandfather Other
Macular Degeneration Mother Father Sibling Paternal Grandmother Maternal Grandmother Paternal Grandfather Maternal Grandfather Other
Eye Injury Mother Father Sibling Paternal Grandmother Maternal Grandmother Paternal Grandfather Maternal Grandfather Other
Retina Disease Mother Father Sibling Paternal Grandmother Maternal Grandmother Paternal Grandfather Maternal Grandfather Other
Other Eye Disease Mother Father Sibling Paternal Grandmother Maternal Grandmother Paternal Grandfather Maternal Grandfather Other
Strabismus Mother Father Sibling Paternal Grandmother Maternal Grandmother Paternal Grandfather Maternal Grandfather Other
Amblyopia Mother Father Sibling Paternal Grandmother Maternal Grandmother Paternal Grandfather Maternal Grandfather Other
Blindness/ Vision Loss Mother Father Sibling Paternal Grandmother Maternal Grandmother Paternal Grandfather Maternal Grandfather Other
Diabetes Mother Father Sibling Paternal Grandmother Maternal Grandmother Paternal Grandfather Maternal Grandfather Other
Cancer Mother Father Sibling Paternal Grandmother Maternal Grandmother Paternal Grandfather Maternal Grandfather Other
>

Heart Disease Mother Father Sibling Paternal Grandmother Maternal Grandmother Paternal Grandfather Maternal Grandfather Other
Other Family History


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