Patient Registration And History Form Family Eye Health Associate

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PATIENT REGISTRATION AND HISTORY FORM ~ FAMILY EYE HEALTH ASSOCIATES
PATIENT INFORMATION:
Name (Last, First, MI)_________________________________________________ Date:_____________________
Address:________________________________________City____________________State_____Zip___________
Home Phone__________________________ 2nd Phone_______________________________ Work Cell
E-Mail________________________________________________________________________________________
Gender: M
Birthdate_____________________ Age__________
F
Occupation____________________________ Employer_______________________________________________
In case of emergency, contact__________________________________________________________________
Relationship____________________________________ Phone_________________________________________
If you are a new patient, who may we thank for referring you?____________________________________________
INSURANCE INFORMATION:
Insurance #1
Insurance holder________________________________ Relationship_____________________Date of Birth_______
Insurance Company_________________________________________Policy #_____________________________
Insurance #2
Insurance holder________________________________ Relationship_____________________Date of Birth_______
Insurance Company_________________________________________Policy #_____________________________
HEALTH HISTORY:
Do you have or have you had any of the following?:
 AIDS/HIV
 High blood pressure
 Carotid Artery Disease
 Rheumatoid arthritis
 High Cholesterol
 Thyroid disease (Hyper/Hypo)
 Asthma
 Kidney disease
 Tuberculosis
 Emphysema
 Lupus
 Sarcoid
 Hay fever/allergies
 Crohn’s Disease
 Multiple sclerosis (MS)
 Heart disease
 Colitis
 Migraines
 Heart attack. When?_________
 Rosacea
 Anxiety/Depression
 Hepatitis
 Stroke. When?____________
 Cancer: Where?_____________
Are you diabetic? Y N If YES please fill out this section:
How many years?____
How do you control it?
Diet
Medication
Insulin
Average blood sugar reading?_________ Your last Hemoglobin A1C reading (if known)?___________
Do you see a specialist for your diabetes? N Y If so, who?_______________________________
Are you pregnant or nursing? Y N
Do you smoke?
NeverCurrently
Quit. What year did you quit?_________
Please list your current medications(Name/mg/how often):
Please list your allergies:
____________________________________________________
____________________________
____________________________________________________
____________________________
____________________________________________________
____________________________
____________________________________________________
____________________________

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