Patient Registration New patient registration form. URLThis field is for validation purposes and should be left unchanged.Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address City State ZIP Code How did you hear about us?Someone in my family goes hereFriend or colleagueInternet search or Google reviewsFacebookInsuranceSeen while driving byReferred by my doctorPrinted adOnline adOtherWho referred you? We would like to send them a Thank You.Briefly describe any problems your experiencing with your eyes or vision.Current Eye Problems None Itchy / allergy eyes Dry eyes Glaucoma Strabismus (lazy eye) Cataracts Macular degeneration Past Eye Problems None Conjunctivitis (pink eye) Eye allergies Corneal abrasion Eye surgery Eye injuries Corneal ulcer Styes / eyelid infections Do any FAMILY MEMBERS have any eye problems? None Cataracts Glaucoma Macular degeneration Retinal detachment Lazy eye / amblyopia Blindness Do you wear glasses?I have never worn glassesI currently wear glassesI have worn glasses but not latelyDo you wear sunglasses when outdoors?AlwaysOftenRarelyNeverDo you wear contact lenses?I have never worn contactsI currently wear contactsI used to wear contacts but not latelyWhat BRAND of contacts do you wear?------- Alcon -------Air OptixAir Optix Night and DayDailies Aquacomfort PlusDailies Total 1------- Bausch + Lomb ------Biotrue ONEdayUltraPurevision 2SofLens Daily Disposable------ CooperVision -------AvairaBiofinityAquaclearClariti 1 Day DisposableFresh Day Daily DisposableMyDay Daily Disposable------ Vistakon ------1-Day Acuvue MoistAcuvue 2Acuvue Oasys (2 week)Acuvue Oasys 1 DayAcuvue VitaContact Lens Power LEFT EYEContact Lens Power RIGHT EYEDo you have any medical conditions?(Required) Yes (select conditions below) None Please select any conditions you have. ADHD Anxiety / Panic disorder Allergies / hayfever Asthma Bleeding problems / anemia Bronchitis Crohn's disease Depression Diabetes Dry throat / mouth Eczema Emphysema Fatigue Fever Fibromyalgia Heart disease High blood pressure High cholesterol Hormone dysfunction Kidney disease Leukemia Lupus Migraines / headaches Multiple sclerosis Neurologic (other) Osteoarthritis Ovarian / uterine cancer Prostate cancer Psoriasis Psychologic (other) Reflux disease Rheumatoid arthritis Rosacea Sinus conditions Stroke Thyroid dysfunction Weight loss/gain List any medications you currently takeList any medications you are ALLERGIC toPrimary care physician nameWhat is your occupation?Please list any hobbies or sports you participate in.Have you ever smoked?Never smokedCurrent smokerFormer smokerNotice of Privacy PracticesOur Notice of Privacy Practices is a complete description of how O’Fallon Family Eyecare uses and protects your medical information and personal data. If you have not already received a copy of our Privacy Practices, please ask one of our staff members for a printed copy or we can e-mail it to you in PDF format. By checking this box, you are only acknowledging that you have received a copy of our Notice of Privacy Practices or had the opportunity to review the notice. You can also ask for a copy when you arrive for your appointment.I have been notified of the privacy practices.CAPTCHA Δ
