Patient Registration & Medical History Form
(Please be sure to bring your Medical Insurance Card, any Eyewear, Contact Lenses, and
Contact Solution)
First Name: __________________Last Name: ____________________ Middle Initial: ___ Preferred Name: _____________
Birth Date: ______________ Social Security Number: ________________
Sex: M / F Marital status:
Single Married Other
Address: ____________________________________________ City:______________________ State: _______ Zip:____________
Which phone number do you prefer?
Home
Work
Cell Home #____________ Work #____________Cell #______________
Email address: _____________________________________Occupation:
How did you hear about us? ______________________________
_Referred by: ________________________
____
Family Members: __________________________________________ Are they patients at this office? _______________________
Hobbies: _____________________________________________________________________________
________
Insurance Information
Primary Medical Insurance:
Vision Insurance:_______________________________________
Policy Holder’s Name:
Policy Holder’s Social Security Number: ____________________
Policy Holder’s Birth Date:
Policy Holders Employer: ___________________ __________
Reason For Visit
How can we help you today? In this space please check/explain any signs and/or symptoms you are experiencing.

Loss of vision
Dry eyes
Light sensitivity
Sandy/gritty feeling
Floaters
Blurred vision
Red eyes
Tired eyes
Eye pain/soreness
Crossed eyes
Double vision
Burning/itching
Glare
Watery eyes
Flashes of light
Other:_____________
Patient History
Last Medical Exam:_______________________________Physician/Clinic:__________________________________________
Have you had any surgeries, major injuries, or hospitalizations? Y / N____________________________
Do you smoke? Y N How much per month? _________Do you consume alcohol?
Are you interested in LASIK surgery? Y
__
Y N If yes, how much? __ _
_
N
Last Eye Exam (estimate):___________________________
_ Where:___
_________________________
Glasses: Do you currently wear glasses? Y N
Contact Lenses: Do you wear contact lenses? Y N What type of contact lenses do you wear?
What is the brand? _______________What are the powers of your contact lenses?
Soft
Rigid
Right:_________ Left:_________
How old is your current pair of contact lenses? ______ Weeks/ Months / Years Do you sleep in your contact lenses? Y
How often do you replace your contact lenses?
Daily
What solutions do you use with your contact lenses?
2 weeks
Renu Optifree
Monthly
N
Other:______________
Revitalens
Biotrue Clear Care Other
Are you taking any medications: Y / N Please List: ____________________________________________________________
________________________________________________________________________________________________________
Do you have any allergies to medications: Y / N List: ___________________________________________________________
List any other allergies: ___________________________________________________________________________________
Family History
Has anyone in your family been diagnosed with any of the following (check all that apply):
No problems
Diabetes
High blood pressure
Heart Disease
Cancer
 Thyroid Issues
Has anyone in your family been diagnosed with any of the following eye problems (check all that apply):
No problems
Glaucoma
Amblyopia (lazy eye)
Strabismus (eye turn)
Cataracts
Retinal Detachment
Macular degeneration
Review of Systems
Please circle the condition(s) that you have. All of these may affect the health of your eyes.
Ocular (Eye)
Constitutional
Ear/Nose/Mouth/Throat
Glaucoma
Amblyopia (Lazy Eye)
Cataract
Inflammatory Disorder
Dry Eye
Retinal problems
Macular Degeneration
Strabismus (Eye Turn)
Fever
Weight Loss/Gain
Cancer
Fatigue Syndrome
Developmental Disability
Sinus Congestion
Laryngitis
Dry Mouth
Hearing Loss
Sinusitis
Neurological
Psychiatric
Cardiovascular
Migraines
Cerebral Palsy
Multiple Sclerosis
Tumor
Epilepsy
Stroke/CVA
Depression
Anxiety
Attention Deficit Disorder
Bipolar Disorder
Vascular Disease
Stroke
Congestive Heart Failure
Heart Disease
High Blood Pressure
Respiratory
Gastrointestinal
Genitourinary
Emphysema
Bronchitis
COPD
Asthma
Sleep Apnea
Colitis
Crohn’s disease
Ulcer
Irritable Bowel Syndrome
Acid Reflux
Celiac Disease
Prostate Disease/Cancer
STD
Kidney Disease
Nursing
Pregnant
Benign Prostate Hypertrophy
Musculoskeletal
Integumentary (Skin)
Endocrine
Ankylosing Spondylitis
Fibromyalgia
Muscular Dystrophy
Osteoarthritis
Osteoporosis
Gout
Rosacea
Psoriasis
Eczema
Herpes Simplex/Cold Sores
Herpes Zoster/Shingles
Insulin Dependent Diabetes (Type I)
Non-Insulin Diabetes (Type II)
Hormonal Dysfunction
Thyroid Dysfunction (Hypo/Hyper)
Blood/Lymph
Allergy/Immunologic
Other: Please list
Anemia
Large volume blood loss
Ulcer
High Cholesterol
Rheumatoid Arthritis
Lupus
Allergies: Drug/ Environmental
Sjogren’s Syndrome
NOTICE OF PRIVACY PRACTICES: I have been shown or offered a copy of Precision Eye Care’s statement on privacy policies that is
displayed at our front desk.
AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize Precision Eye Care, LLC to release any medical or incidental information
that may be necessary for medical benefit in processing applications for financial benefit. This includes, but is not limited to, my insurance
company, rehabilitation services, social security administration, and worker’s compensation.
CONSENT FOR TREATMENT: I hereby authorize Precision Eye Care, LLC to administer diagnostic and medical procedures as may be
necessary for proper health care.
OFFICE POLICY ON PAYMENT: I understand that I am responsible for payment of all charges. As a courtesy, my insurance will be billed for me.
It is my responsibility to pay any deductible, co-pay or any other balance not paid by my insurance company. I authorize insurance benefits to be
paid directly to the provider. I understand that any remaining balance on my account after 30 days will accrue interest at an annual rate of 18%
and that I will be responsible for any reasonable costs associated with the collection of past-due balances.
VISION PLAN COVERAGE: I understand that only one vision plan may be used for exam/materials per visit, per patient and that the vision plan to
be used must be chosen before the exam occurs and cannot change at a later date.
___________________________________________
PRINTED NAME OF PATIENT OR PATIENT REPRESENTATIVE
_______________________________________
DATE
______________________________________________________
SIGNATURE
________________________________________
RELATIONSHIP TO PATIENT