Formulario de Registro del Paciente "*" indicates required fields Please complete the information below and submit the form online or, if you prefer, print out the form after full or partial completion and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.Patient InformationToday's DatePatient Name* First Last Patient Date of Birth*Date of Last Eye ExamWhere?Do you have any allergies to medications? No Yes If Yes, list medication(s) and reaction below:List ALL current medications:Include Name of Medication, Dosage, Frequency TakenList any major injuries, surgeries and or hospitalizations you have had and date(s).Medical InformationDo you currently or ever had any problems in the following areas? (If yes, check the box)General/Constitutional Fever, Weight Loss/Gain Ears/Nose/Throat Allergies/Hay Fever Sinus Congestion Chronic Cough Dry Throat/Mouth Respiratory Asthma Chronic Bronchitis Emphysema Lymphatic/Hematologic Anemia Bleeding Problems Integumentary Eczema Psoriasis Cancer Gastrointestinal Chronic Diarrhea Chronic Constipation Ulcer Crohn’s Colitis Geintourinary Genitals/Kidney/Bladder Prostate (men) Ovaries (women) Musculoskeletal Muscle Pain Joint Pain Cardiovascular High Blood Pressure High Cholesterol Stroke Heart Disease Neurological Headaches Migraines Seizures Multiple Sclerosis Paralysis Psychiatric Depression Panic Disorder Schizophrenia Endocrine Diabetes Thyroid Dysfunction Hormonal Dysfunction Allergy/Immunological Food/Drug Allergy Environmental Allergy Rheumatoid Arthritis Lupus Personal Eye InformationHave you had any of the following? (if yes, check the box) Eye Surgery Eye Injury Crossed Eyes Drooping Eyelid Glaucoma Macular Degeneration Cataracts Eye Infections Retinal Detachment Glasses Contact Lenses Other If you answered Yes or Other, please explain:Your Eye SymptomsDo you (patient) experience any of the following? (If yes, check the box) Blurred Vision Double Vision Loss of Vision Eye Pain Tired Eyes Red Eyes Watery Eyes Itchy Eyes Burning Eyes Dry Eyes Mucous Discharge Flashing Lights Floating Spots Reading Difficulties Other If you answered Yes or Other, please explain:Family HistoryNote any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.Has anyone in the patient’s family (blood relative) had any of the following? High Blood Pressure Diabetes Heart Disease Cancer Glaucoma Macular Degeneration Retinal Disease Cataracts Lazy Eye Crossed Eyes Blindness Other If you answered Yes or Other, please explain:Social HistoryThis information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer. Please check the box below of you prefer to discuss with the doctor instead.I prefer to discuss my Social History information directly with my doctor. Yes (optional)Do you drive? No Yes If Yes, do you have visual difficulty when driving?Do you use tobacco products? No Yes If Yes, list type/amount/how long:Do you drink alcohol? No Yes If Yes, list type/amount/how long:Do you use other drugs? No Yes If Yes, list type/amount/how long:The information provided is true and complete to the best of my knowledge. Patient (or Guardian’s) Signature*Date MM slash DD slash YYYY Name of Person Completing Form (if not patient)Relationship to PatientCAPTCHABroken Appointment Policy Acknowledgement* I agree to the Broken Appointment Policy Acknowledgement.I understand that Buena Vista Optical requires at least 24 hours' notice to cancel or reschedule any appointment. I acknowledge that failure to provide at least 24 hours' notice, or missing an appointment without notice, will result in a $29.00 missed appointment fee, as stated in the practice's policy.Consent* I agree to the HIPAA policyPhoneThis field is for validation purposes and should be left unchanged. Δ
