PATIENT REGISTRATION FORM

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PATIENT INFORMATION
MaleFemale
PERSON RESPONSIBLE FOR THE BILL (ONLY IF APPLICABLE IF OTHER THAN THE PATIENT)
INSURANCE INFORMATION
ADDITIONAL PATIENT INFORMATION
Full-TimePart-Time
MEDICAL INFORMATION
I. PAST MEDICAL HISTORY
AsthmaArthritisCancerBreast CancerColon CancerLeukemiaLung CancerLymphomaProstate CancerDiabetesEmphysema (COPD)Heart DiseaseAtrial Fibrilation (irregular heartbeat)Coronary Artery DiseaseHepatitsHigh Cholesterol (Hypercholesterolemia)High Blood Pressure (Hypertension)HIVStrokeThyroid DiseaseHyperthyroidismHypothyroidism
II. OCULAR HISTORY (List any eye conditions andor eye surgeries)
CataractsCrossed Eyes (Strabismus)DiabetesEye DisordersGlaucomaHeart DiseaseHigh Blood Pressure (Hypertension)Lazy Eyes (Amblyopia)Retinal Detachments
III. CURRENT MEDICATIONS
IV. MEDICATION ALLERGIES
V. SOCIAL HISTORY
VI. REVIEW OF SYSTEMS (Do you have any problems in the following areas? Check all that apply)
NormalFever
NormalBlurred Vision
NormalHearing Loss
NormalChest Pain
NormalShort of Breath
NormalStomach Pain
NormalFree Bleeder
NormalWeakness
NormalTumors
NormalNumbness
Currently Pregnant