Patient Registration And Health History Form

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Patient Registration and Health History Check In:_________
Last Name:_______________________________First Name:_____________________________MI:_______ Date: _____________
Preferred Name/Nick Name:___________________________________
Title: Dr Mr Mrs Miss Other__________
Sex:
Male/Female
Birthdate: _____________________
Age:__________
Last 4 SSN: ____________
Mailing Address: ___________________________________ City: ________________
State: __________
Zip: _________
Home Phone: (____)_________________________ Cell:(____)______________________ Work: (____)_______________________
Email Address: _______________________________________________ Preferred correspondence: Email Postal mail Phone
Marital Status: Married / Single / Widowed / Other
Partners Name: _________________________________
Preferred Language: English, Spanish, Other _______________________ Height _________ Weight_________________
Race: Am Indian, Asian, Black or African Am, Hispanic, White, Other ______________
Ethnicity: Hispanic, German, French, Chinese, Korean Norwegian, Other_________________
Employer: ______________________________ ______________Occupation: ____________________________________________
Full Time: ______ Part Time: ______ Retired: _______
Student:
_____Yes
_____No
Grade Level _________
Insurance Company: ___________________ (Please present your card so we can make a copy)
Who is responsible for the Account? _____ Self ______ Other : (fill in information below if other )
Name: __________________________________________ Address: ____________________________________________________
City: ___________________________________________
State: ________________
Zip: _________________
Notice of Privacy Practice
I authorize the release of any medical or other information necessary to process insurance. I authorize payment of benefits to Robeson
Family Vision Center. I understand that if services and /or materials are not covered I will be responsible for charges incurred.
I understand that there will be finance charges on all past due accounts over 30 days.
I acknowledge that I have had the opportunity to review and have been offered a copy of Robeson Family Vision Center’s Notice of
Privacy Practice.
_________________________________________________ _______________________________________
Signature
of patient or responsible party
Date
▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬
OCULAR HISTORY
Reason for today’s exam? ______________________________________________________________________________________
Are you planning to get new glasses today? Yes or No
Referred Here by: ____________________________ Last Exam: ____/____/____ Examining Dr: ____________________________
Do you currently have any problems in the following areas? If YES, please provide details
YES
NO
YES
NO
DETAILS
DETAILS
EYES
EYES
Loss of Vision
Burning
Blurred Vision
Excess Tearing
Foreign Body Sensation
Fluctuating Vision
Night Vision Troubles
Infection of Eye
Glare/Light Sensitivity
Tired Eyes
Loss of Side Vision
Drooping Eyelid
Double Vision
Crossed Eye/Lazy
Dryness
Contact Lens
Discomfort
Mucous Discharge
Headaches
Sandy or Gritty Feeling
See Floaters/Spots
Itching
See Flashing Light
PLEASE SEE BACK OF FORM

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