PATIENT REGISTRATION
 
PATIENT INFORMATION
     
Name: Date of Birth: Age:   Sex: M F
(First) (MI) (Last)
Month   day   year  
 
Address:
Street City State Zip
 
Home/Cell: Work: Email:
 
Occupation: Employer:
 
Do you have a specialized Driver\'s License?
CDL Pilot Motorcycle Other:
 
Do you have any special vision requirements or restrictions for your job?
 
Emergency contact name: Phone:
 
INTEREST IN LASIK
 
Rate your satisfaction of your current glasses/contacts:
Extremely Satisfied Very Somewhat Not Very Not at all
 
What activities or hobbies would you enjoy more without the dependency of glasses/contacts? (swimming, skiing, movies, etc.)
 
How did you hear about us?
   
How many LASIK providers are you evaluating?
One Two More than two
 
What is your biggest concern about having LASIK?
 
Will you use funds from an employer sponsored flexible spending plan to pay for this procedure? Yes No
 
If our schedule allows, would you be interested in having laser vision correction on the same day as your candidacy evaluation?
  Yes No Maybe  
 
RELEASE OF INFORMATION/OTHER

I understand that this evaluation is for laser vision correction purposes only and is not a substitute for a routine eye examination. If I wish to have a copy of my examination records released to myself or another provider, I acknowledge that there may be a charge to me. I further understand that for internal training purposes only, my preoperative examination may be recorded with video and/or audio equipment. If I stated that I was referred by my Managed Care plan, I attest that I am a current member or eligible dependent of the Managed Care plan that I have indicated. Should it be determined that I am not an eligible member or dependent, I agree to reimburse the amount of the plan discount. Any applicable Managed Care discount must be indicated before payment or it will be forfeited.

 
Signature of patient   Date  
 
 
MEDICAL HISTORY
 
Do you have or have you ever been treated for the following:
Stroke Ulcer Heart Disease Currently Pregnant/Nursing
Seizure Stomach Disorder Heart Attack Rheumatoid Arthritis
Brain Tumors Digestive Disease Bypass Surgery Sarcoid
Brain/nerve disorders Hepatitis B or C Other Heart Disease Lupus
Migraines Liver Disease High Blood Pressure Acne Rosacea
Emphysema Kidney Stones Irregular Heart Rhythms Keloids
Asthma Kidney Infection thyroid-disease HerpesZoster (Shingles)
Tuberculosis Nephritis Other Lung Disorders Psoriasis
Prostate Disease Pneumonia Diabetes Sleep Disorders
MS HIV/AIDS Cancer or tumor, Type:
Inflammatory Bowel Disease Other
 
Do you have an implanted pacemaker, defibrillator, or other battery powered medical device? Yes No
Please list any previous surgical procedures that you have had:
 
 
Do you currently take any of the following medications? (Please check all that apply)
 
Birth Control Pills    Antihistamines    Beta Blockers    Anti Depressants    Diuretics (Lasix)
Hormone Replacement Therapy    Accutane (even previously)    Cordarone    Imitrex
 
List all current medications and dosage:
I take no medications
List all medications that you are ALLERGIC to:
I have no known drug allergies
Primary Care Doctor's Name: Phone Number:
 
EYE HEALTH HISTORY
 
When was your last eye exam?
 
Have you experienced any of these eye/health issues in the last 3‐6 months?
Stinging Tearing Itching Grittiness Burning
Dryness Glare Redness Trouble with night vision
Occasional Blurred Vision Double Vision Eye Abrasion or Erosion
Decreased contact lens wearing time Light Sensitivity Ocular Discomfort (aching
 
Have you or a family member (parent or sibling) ever been diagnosed with or treated for:
 
Cataracts Self Family Glaucoma Self Family Strabismus (eye turn) Self Family
Retinal Disease Self Family Amblyopia (lazy eye) Self Family Diabetes Self Family
Blindness Self Family Keratoconus or other corneal diease Self Family
 
Have you ever had any surgery, injury or laser treatments to the eye? No Yes (please describe below)
 
 
How are you currently managing your vision condition:
 
Glasses How old are your current glasses?:
   
Contacts: Type: Soft Toric Gas Perm
 
Do you sleep in them? Yes No How many years have you worn contacts?
 
When did you last wear your contacts?
 
 
 
  For Office Use Only:___________________________