Simon Eye Center - Patient Registration

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Patient Registration Form for Simon Eye Associates

Please complete the information below and print out the completed form
and bring it with you when you come to our office.

Name: M.I. Salutation

Address: City: State: ZIP:

Date of Birth: // Age: Home Phone: Business Phone:

SS#: E-mail Address:

Employer: Occupation:

How were you referred to our office?

Friend or Family Member:	Insurance Company	Yellow Pages
Family Doctor:	Received Mailing	Newspaper
Ophthalmologist:	Internet	Other

Please list all insurances, vision and medical. Please bring all insurance cards with you to your appointment.

PRIMARY INSURANCE INFO	SECONDARY INSURANCE INFO
Insurance Company Name:	Insurance Company Name:
Employer:	Employer:
Identification Number:	Identification Number:
Group Number:	Group Number:
Name of Policy Holder:	Patient's Relation to Insured:
Insured's D.O.B.:	Insured's D.O.B.:
Insured's SS#:	Insured's SS#:

EYEGLASS HISTORY

Do you wear glasses?

Yes

Full Time

Part Time

Distance

Near

Glasses owned:	Single Vision	Bifocals	Safety Glasses	Backup Glasses
.	Progressive	Trifocals	Sports Glasses	Other

Do you use a computer?

Yes

Hours per day:

Distance from computer:

Do you have problems with glare?	Yes	No
Do you have problems with night vision?	Yes	No
Are you allergic to Nickel (eg; jewelry or eyeglass frames discoloring your skin)?	Yes	No
If you currently wear eyeglasses, are there certain times when you would rather not?	Yes	No
If you currently wear eyeglasses, does your spare pair have your correct prescription?	Yes	No
Do your sunglasses have UV (ultra-violet) protection?	Yes	No
Are your sunglasses your current prescription?	Yes	No

CONTACT LENS HISTORY

Do you currently wear contact lenses?	Yes	No
Have you ever tried to wear contact lenses?	Yes	No	Reason for stopping:
Are you interested in changing or enhancing your eye color?	Yes	No
If you currently wear contact lenses, do your backup eyeglasses have your correct prescription?	Yes	No

Answer the questions below only if you currently wear contact lenses:

What type or brand of contacts do you wear?

	1.	How old are your current lenses?
	2.	How often do you replace or dispose of your contact lenses?
	3.	What brand of solution do your lenses soak in overnight?

What is your typical wearing schedule?

Hours/day

Days/week

Are you having any problems with your current contact lenses?

Yes

Would you like to be evaluated for refractive laser surgery?	Yes	No
Would you like to be evaluated for a NON-surgical method to correct your vision?	Yes	No

MEDICAL HISTORY

Date of last Eye Exam:	Where did you get your last Eye Exam?
Date of last Physical Exam:	Name of PCP (Primary Care Physician):

EYE HISTORY:

With vision correction being used, do you suffer from any of the following?

Headaches	Yes	No	Foreign Body Sensation	Yes	No	Blurred Vision at Distance	Yes	No
Glare/Light Sensitivity	Yes	No	Infection of Eye or Lid	Yes	No	Blurred Vision at Near	Yes	No
Tired Eyes	Yes	No	Itching	Yes	No	Distorted Vision (haloes)	Yes	No
Amblyopia (lazy eye)	Yes	No	Mucous Discharge	Yes	No	Double Vision	Yes	No
Burning	Yes	No	Ptosis (drooping eyelid)	Yes	No	Floaters or Spots	Yes	No
Dryness	Yes	No	Redness	Yes	No	Fluctuating Vision	Yes	No
Epiphora (excess tearing)	Yes	No	Sandy or Gritty Feeling	Yes	No	Loss of Vision	Yes	No
Eye Pain and/or Soreness	Yes	No	Strabismus (crossed eye)	Yes	No	Loss of Side Vision	Yes	No

Many disesases of the body have grave eye health consequences. Please answer the following questions. While they may seem unrelated to an eye problem, it is crucial to your care that we ask them.unrelated to an eye problem, it is crucial to your care that we ask them.

Have you ever been treated for any MEDICAL CONDITIONS? (eg. Diabetes, high blood pressure, arthritis, etc.)?	Yes	No
If YES, please explain:
Have you ever had any EYE DISEASE? (eg. Glaucoma, cataract, wandering or “lazy” eye, retinal detachment)?	Yes	No
If YES, please explain:
Have you ever had any SURGERY for your eyes or any other condition?	Yes	No
If YES, please explain:
Do you take any MEDICATIONS?	Yes	No
If YES, please explain:
Do you have any food or drug ALLERGIES?	Yes	No
If YES, please explain:

REVIEW OF SYSTEMS:

Many diseases of the body have grave eye health consequences.
Please answer the following questions.
While they may seem unrelated to an eye problem, it is crucial to your care that we ask them.

Do you currently have any of the following problems?	Yes	No	If YES, please explain:
Chronic fever, unexpected weight loss/gain, fatigue
Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat)
Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet)
Respiratory problems (eg. Shortness of breath, wheezing, coughing)
Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting)
Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems)
Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints)
Skin problems (eg. Rashes, excessive dryness, growths or lumps)
Neurological problems (eg. Numbness, weakness, headaches, ?blackouts?)
Psychiatric problems (eg. Depression, anxiety)
Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time)
Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands)
Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)

FAMILY HISTORY:

Do any MEDICAL or EYE diseases run in your family (BLOOD relatives) (eg. Diabetes, high blood pressure, cancer, glaucoma, macular degeneration, etc.)? Yes No

If YES, please explain:

SOCIAL HISTORY:

Do you drink alcohol?	No	Occasionally	1/day	2-3/day	4+/day
Do you smoke?	No	Occasionally	1/2 pack/day	1 pack/day	1+ pack/day
Marital Status	Single	Married	Other