Patient Registration Form Name(Required) First Last Phone(Required)Email(Required) HEALTH HISTORYConstitution: Appetite changes ! Fatigue ! Sleep Changes ! Fever ! Itching ! Light-headedness ! Falls ! Mood Swings ! Muscle Cramps ! Rash ! Night Sweats ! Loss of Sensation ! Weight Gain ! Weight Loss ! Cardiovascular: Chest Pain ! Heart disease ! Heart Failure ! Heart Murmur ! High Blood Pressure ! High Cholesterol ! Irregular Heart Beat ! Pacemaker ! Shortness of Breath ! Stent ! Stroke ! Varicose Veins ! Ears, nose, mouth, & throat: Allergies ! Chronic Colds ! Chronic Sinusitis ! Dentures ! Dermatitis ! Dizziness ! Earaches ! Hearing Aids ! Hearing Loss ! Nose Bleeds ! Cancer ! please explain:Musculoskeletal: Arthritis ! Back Pain ! Bone Cancer ! Carpal Tunnel Syndrome ! Cerebral Palsy ! Fibromyalgia ! Gout ! Joint Pain ! Multiple Sclerosis ! Osteoarthritis ! Osteoporosis ! Rheumatoid Arthritis ! Sjogren’s Syndrome ! Gastrointestinal: Crohn’s Disease ! Constipation ! Diarrhea ! Heartburn ! Hepatitis ! Hernia ! Ulcers ! GERD ! Gastric Reflux ! Genitourinary: Bladder problems ! Dialysis ! Frequent Urination ! Kidney Problems ! Ovarian Cancer ! Prostate Cancer ! Prostate Problem ! Psychiatric: Anxiety ! Depression ! Dementia ! Mood Swings ! Panic Episodes ! Paranoia ! Phobias ! Suicidal Thoughts ! Respiratory: Asthma ! Bronchitis ! Cough ! Emphysema ! Lung Cancer ! Pleurisy ! Pneumonia ! Sleep Apnea ! COPD ! Integumentary: Acne ! Acne Rosacea ! Basal Cell Carcinoma ! Dermatitis ! Eczema ! Lupus ! Psoriasis ! Skin Cancer ! Neurological: Bell’s palsy ! Epilepsy ! Headaches ! Migraines ! Paralysis ! Seizures ! Stroke ! TIA ! Vertigo ! Endocrine: Diabetes Type 1 ! Diabetes Type 2 ! Gestational Diabetes ! Hypoglycemia ! Hyperthyroidism ! Hypothyroidism ! Hematologic/Lymphatic: Anemia ! Excessive Bleeding ! Leukemia ! Lymphoma ! Multiple Myeloma ! Untitled Allergic disorders ! Autoimmune Disorders ! Drug Hypersensitivity ! Food Allergy ! Immunologic: HIV/Aids ! Leukemia ! Lupus ! Psoriasis ! Rheumatoid Arthritis ! Transplant ! Past/Present/Family Ocular History: (Check All That Apply)Glaucoma: Self List any associated surgeries: Family Specify family members: Cataracts: Self List any associated surgeries: Family Specify family members: Macular Degeneration: Self List any associated surgeries: Family Specify family members: Eye Injury: Self List any associated surgeries: Family Specify family members: Retinal Disease: Self List any associated surgeries: Family Specify family members: Blindness: Self List any associated surgeries: Family Specify family members: Strabismus: Self List any associated surgeries: Family Specify family members: Amblyopia: Self List any associated surgeries: Family Specify family members: Diabetes: Self List any associated surgeries: Family Specify family members: Dry Eye: Self List any associated surgeries: Family Specify family members: Eye Surgery: Self List any associated surgeries: Family Specify family members: Refractive: Self List any associated surgeries: Family Specify family members: Cancer: Self List any associated surgeries: Family Specify family members: Heart Disease: Self List any associated surgeries: Family Specify family members: Other Disease:WhoSocial History: (Check All That Apply)Tobacco Use: None/Never ! Cigarettes ! Pipe ! Chewing tobacco ! Snuff ! Quit Smoking ! Illegal Drug Use: None/Never ! Cocaine ! Crack ! Heroine ! Marijuana ! Methampthetamine ! Speed ! Alcohol Use: None/Never ! Beer ! Liquor ! Wine ! Social ! Do you work on a computer? Yes No How many hours per day?FOR WOMEN:Are you pregnant? Yes No Are you nursing? Yes No Medications:(Please list ALL prescription & over-the –counter medications you currently take)Name of Medication:Dosage:Taken For:Taken For: Add RemoveDo you have any allergies to medications? Yes No please explain:CAPTCHA Δ
