PATIENT REGISTRATION AND HEALTH HISTORY FORM
PATIENT REGISTRATION AND HEALTH HISTORY FORM
Patient’s Name ______________________________ Date
Address: ___________________________________ Birthdate ________________________
___________________________________________ Soc. Sec. #:
(City) (State) (Zip)
Home Tel #
Parent or Responsible
Party’s Name _______________________________ Cell Phone #
Vision Insurance E-mail address
What is your Occupation: ____________________________________________
Primary Care Dr: _______________________________ Phone # ____
Coronavirus Screening (Yes or No: If Yes please reschedule your appointment in 14 days):
____ Experienced Fever, Cough, Difficulty Breathing or Flu like symptoms in the past 7 days?
____ Been diagnosed with COVID 19 or been in contact with anyone diagnosed with COVID 19 in
the past 14 days?
____ Traveled Internationally in the past 14 days
____ Temperature to be taken on day of appointment
Patient Demographics (Required for Electronic Health Record Federal mandates):
Preferred Language: _____ English _____ Other: ____________________
Tobacco Use: _____ Never _____ Current _____ Former
Contact Preference: _____ Phone _____ Email _____ Postal
Ethnicity: _____ Caucasian _____ African American _____ Hispanic
_____ Asian _____ Middle Eastern _____ Other
HOW WILL TODAY’S EXAMINATION BE PAID FOR (CIRCLE ONE):
CASH CHECK CREDIT CARD INSURANCE MEDICARE OTHER
Patient Signature X ___________________________________________________________________
Thank you for your trust in Fortney Eyecare!
PLEASE COMPLETE BACK SIDE
Patient Name: ______________________ D.O.B. Today’s date______________
Patient’s Health History
(Check those you have had)
Medical:
___ Asthma
___ Cancer
___ Cholesterol
___ Diabetes
___ Drug sensitivity
___ Hay fever
___ Heart condition
___ High blood pressure
___ Migraine headaches
___ Skin condition
___ Thyroid condition
___ Other: __________________
Ocular:
___ Blindness
___ Cataracts
___ Color Deficiency
___ Dry Eye
___ Glaucoma
___ Macular Degeneration
___ Retinal Disease
___ Other: __________________
Family Health History
(Check those family have had)
Medical:
___ Asthma
___ Cancer
___ Cholesterol
___ Diabetes
___ Drug sensitivity
___ Hay fever
___ Heart condition
___ High blood pressure
___ Migraine headaches
___ Skin condition
___ Thyroid condition
___ Other: _______________
Ocular:
___ Blindness
___ Cataracts
___ Color Deficiency
___ Dry Eye
___ Glaucoma
___ Macular Degeneration
___ Retinal Disease
___Other: _______________
Patient’s Visual Symptoms
(Check those you have)
___ Abrasion (Cornea)
___ Blurry Vision
___ Allergy
___ Diplopia (Double Vision)
___ Eye Turn
___ Field Loss
___ Floaters (recent onset)
___ Flashes (recent onset)
___ Foreign Body
___ Headache / Migraine
___ Lumps / Bumps
___ Pain
___ Red eyes
___ Trauma / Burn
___ Visual Symptoms: fatigue, glare,
squinting, sensitivity to light
___ Contact Lens Check
___ Spectacle Recheck
___ Other: ____________________
___ None, routine eye examination
Are you currently pregnant? Yes ______ No ______
Explanation of health history, where necessary: _____________________________________________
_____________________________________________________________________________________
Are you presently taking any medications? Yes _____ No ______
If yes, which ones? Include any eye medications… (If names unknown what are they for)_____________
_____________________________________________________________________________________
List any and all allergies: ______________________________________________________
When was your last visit to your medical physician? __________________________________________
Previous Eye Doctor & last exam: ________________________________ Date: ___________________
Do you wear contact lenses? Yes ____ No ____ If yes, which type? Hard ____ Soft
For Office Use Only:
Old OD: Auto OD: Tono: Type Time OD OS
Rx: Refractor:
OS: OS: NCT ______ _____ _____
War Slide: #2 #4 Far #5 #6 #1
Dbn Slide: #3 #5 Acuity #6 Lat. Phoria #7 Ver. Phoria #8 Visual Fields
Stereo OS Far OU Far OD Far Far Near Far Near OD OS
Result: ______ 20/_____ 20/_____ 20/_____ ______ ______ ______ ______ _____ _____
Unaided FAR OS 20/_____ OU 20/_____ OD 20/_____ _______Near OS 20/_____ OU 20/_____ OD 20/_____
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