Patient Registration for Livermore Optometry

 

Please complete the information below and submit the form online, or if you prefer,
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 No 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 No 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?
4. What is your typical wearing schedule? Hours/day Days/week
5. Are you having any problems with your current contact lenses? Yes No
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 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.

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



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