Ophthalmology Patient Registration Form - Nethery Eye Associates

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PLEASE PRINT
Todays Date: ________________________
Patient Name: ___________________________Primary Care Physician Name: _________________________
Optometrist Name: _______________________Pharmacy Name: ___________________________________
Pharmacy Address, Zip Code and Phone Number: ________________________________________________
________________________________________________________________________________________
Past Medical History: Please check the box and list the date of onset.
Anxiety: _____________________________
Hearing Loss: _________________________
Arthritis: ____________________________
Hepatitis: ____________________________
Asthma: _____________________________
Hypertension: ________________________
Atrial Fib (Irregular Heart Beat): __________
HIV / AIDS: ___________________________
Bone Marrow Transplant:________________
Hypercholesterolemia: _________________
BPH/ Urinary Problems: ________________
Infectious Disease: ____________________
Breast Cancer: _______________________
Leukemia: ___________________________
Colon Cancer: _______________________
Liver Disease: ________________________
COPD / Emphysema: __________________
Lung Disease:_________________________
Coronary Artery Disease: _______________
Lymphoma:___________________________
Depression: __________________________
Prostate Cancer: ______________________
Diabetes Type I: _______________________
Radiation Therapy: ____________________
Diabetes Type II: _______________________
Seizures: ____________________________
End Stage Renal Disease: _________________
Stroke: _____________________________
GERD: ________________________________
Thyroid Disease (Hyper/Hypo): __________
Please list any surgeries you have had:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Ocular History
Have you been diagnosed with any eye conditions / diseases? If yes, please check the box and list the date of
diagnosis.
Cataracts: ____________________________
Macular Degeneration: ___________________
Dry Eyes: _____________________________
Retinal Detachment: _____________________
Glaucoma: ____________________________
Please continue on reverse side

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