Adult Eye Registration and Eye Health "*" indicates required fields Please complete the information below and submit the form online. This form contains confidential information and is delivered to your doctor through a secure Internet connection.Patient InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone*Cell PhoneWork PhoneBest Time to Reach You Email Address Please provide us your email address.Personal InformationGender* Female Male Date of Birth* MM slash DD slash YYYY Social Security Number (last 4 digits only!) Occupation Employer Marital StatusSelect Marital Status >DivorcedLegally SeparatedMarriedSingleWidowedOtherMarital Status - Other Please provide other marital status.Spouse's Name First Last Spouse's Birthdate MM slash DD slash YYYY Spouse's Social Security Number (last 4 digits only!) Spouse's Occupation Spouse's Employer Who may we thank for referring you? What is your main problem or concern?In Case of Emergency - ContactSomeone not living in your household.Name First Last Relationship Home PhoneCell PhoneWork PhoneEye Health HistoryName of Eye Doctor First Last Date of Last Eye Exam MM slash DD slash YYYY Do you wear glasses?* Yes No When do you wear your glasses? All the time Occasionally Reading Driving Watching TV Computers Other Do you wear contact lenses?* Yes No What type of contact lenses do you wear? How often to you wear your current lenses? Hours per day.Describe any problems you may have with your contactsPlease check off if you have any of the following Bloodshot Eyes Blurred Vision - Distance Blurred Vision - Near Burning Eyes Cataracts Color Vision, Poor Crossed Eyes Discharge from Eyes Dizzy Spells Double Vision Dry Eyes Eye Infection Eye Injury Eye Strain Fainting Spells, Blackouts Floaters or Spots Glaucoma Headaches Itching Eyes Light Sensitivity Loss of Vision Migraine Headaches Night Vision. Poor Red Eyes Seeing Halos Seeing Flashes Temporary Loss of Vision Twitching Eyelid Vision Poor Watery Eyes Health HistoryPhysician's Name First Last Date of Last Exam Are you pregnant?Are you pregnant >NoYesNumber of Children Alcohol UseDo you drink alcohol >NoYesTobacco UseDo you smoke >NoYesConditionsIndicate if you and/or a family member has had any of the followingPatient AIDS/HIV Arthritis Artificial Heart Valve Artificial Joint Asthma Bleeding Blindness Cancer Cataracts Chemical Dependency Diabetes Drug Sensitivity Emphysema Epilepsy Eye Surgery Glaucoma Hay Fever Heart Condition Hepatitis High Blood Pressure Kidney Disease Lazy Eye Lupus Migraine Headaches Pacemaker Poor Color Vision Retinal Disease Rheumatic Fever Shingles Skin Condition Stroke Thyroid Condition Tuberculosis Turned eye Family Member AIDS/HIV Arthritis Artificial Heart Valve Artificial Joint Asthma Bleeding Blindness Cancer Cataracts Chemical Dependency Diabetes Drug Sensitivity Emphysema Epilepsy Eye Surgery Glaucoma Hay Fever Heart Condition Hepatitis High Blood Pressure Kidney Disease Lazy Eye Lupus Migraine Headaches Pacemaker Poor Color Vision Retinal Disease Rheumatic Fever Shingles Skin Condition Stroke Thyroid Condition Tuberculosis Turned eye Medicare AuthorizationI request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. Phyllis Liu, OD, FCOVD for any services furnished me by that doctor. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in Item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare Carrier as the full charge, and the patient is responsible only for the deductible coinsurance and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.Name of Beneficiary First Last Signature of BeneficiaryReview of SystemsPlease check off any current conditions you suffer fromGeneral Weight loss or gain Fatigue Fever or Chills Weakness Trouble Sleeping Throat Bleeding Dry mouth Sore throat Hoarseness Thrush Non-healing sores GASTROINESTINAL Bleeding Swallowing difficulties Heartburn Change in appetite Nausea Change in bowel habits Rectal bleeding Constipation Diarrhea Yellow eyes or skin Skin Rashes Lumps Itching Dryness Color changes Hair or nail changes Neck Swollen glands Pain Lumps Stiffness Urinary Frequency Urgency Burning or pain Blood in urine Incontinence Change in urinary strength Head Headache Head injury Neck pain Respiratory Coughing Sputum Coughing up blood Shortness of breath Wheezing Painful breathing Musculoskeletal Muscle or joint pain Stiffness Back pain Red and/or Swelling of joints Trauma Ears Decreased hearing Ringing in ears Earache Drainage Cardiovascular Chest pain or discomfort Tightness Palpitations Shortness of breath w/activity Difficulty breathing lying down Swelling Endocrine Hot or cold intolerance Sweating Frequent urination Thirst Change in appetite Nose Stuffiness Discharge Itching Hay fever Nosebleeds Sinus Pains Vascular Calf pain with walking Leg cramping Neurologic Dizziness Fainting Seizures Weakness Numbness Tingling Tremors Hematologic Ease of bruising Ease of bleeding Psychiatric Nervousness Stress Depression Memory Loss Other Dentures Sore Tongue CommentsIf you have any comments you would like to add, please enter them here.CommentsThis field is for validation purposes and should be left unchanged.