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 Secure .On-Line Pre-Registration
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EXAM REGISTRATION Please answer all the questions  to the best of your knowledge.
You may elaborate on any questions  below, and/or in the office.
Do you currently wear:
Glasses YES NO
Contact Lenses YES NO
Low Vision Aids YES NO
Do you currently have or have you ever had any of the following:
Operations YES
 NO
injuries
Infections
Amblyopia Cataracts
Cataracts
Dry Eyes YES
 NO
Light Sensitivity
Pain
Glaucoma
Lazy Eye
Macular Degeneration YES
 NO
Eye Turn In / Out
Reading Problems
Tracking Problems
Other
Do you Have:
. YES NO
Diabetes
High Blood Pressure
. YES NO
Headaches
.
Medication - List any Medications:
Allergies - List any known Allergies:
Are you currently taking YES NO
prescription or non-prescription drugs?
Do you currently have any Allergies YES NO
known or perceived?
Do you have problems with any of these systems? - Please check all that apply
Allergic / Immunologic YES
 NO
Arthritis
Blood / Lymph
Cardiovascular Heart Disease
Ear / Nose / Throat
Endocrine Glands
Gastrointestinal
Integument Skin
Kidney Problems YES
 NO
Musculature
Nervous
Psychiatric
Respiratory
Skeletal Bones
Thyroid Problems
Other (explain bottom of page)
Do you use - Please select all that apply
Cigarettes? YES NO
Alcohol? YES NO
Other substances? YES NO
Family Eye History - Anyone in patient's family (blood relative) had any of the following?
Cataracts YES
 NO
Cornea Disease
Diabetes
Glaucoma YES
 NO
Lazy Eye
Macular Degeneration
Retina Disease YES
 NO
High Blood Pressure
Other Eye Disorders
Your Surgical History- List any type of surgery and dates of surgery
Physician and Emergency Contact
Family Physician
Referring Physician
Emergency Contact Person
Other Information- Please elaborate on any information or from any "Other" box above.