Online Patient Registration Form Personal and Medical Background Information Form Patient Name* First Last GenderMaleFemaleEmail 1. The main reason/s for today’s visit is / are:2. When was your last: Eye Examination? General Physical?3. MEDICAL HISTORY: Please list ALL … Medical problems (Diabetes, High Blood Pressure, Kidney Disease, Cancer, etc.) Medications that you are taking, and what you are taking them for:4. Have you had any serious EYE or HEAD injuries, illnesses, or surgeries?5. If you have headaches, please describe what part of the head, and how often, and when they began.6. Is there anyone in your family that has had severe eye problems or health problems ?7. Medical Insurance:ID Number:Has this changed since last year?YesNoN/A8. Vision PlanID Number:Has this changed since last year?YesNoN/AThe NEW Daytona Optomap Retinal Examination is prescribed by Dr. Roth to evaluate the health of your retina (back part of the eye). It produces a sharp and wide view of your retina, without using eye drops. The advantages to you are: Fast (less than 1 second per eye). No blurred vision afterwards. You will see the back part of your own eye, and the doctor will explain the findings. This is now part of your permanent record, so we can then compare the retina from year to year. This new technology is a part of our standard of care and the fee for this test is $39.00. This test is not covered by any medical insurance.9. I choose to have the Optomap Retinal Exam:YesNo10. Name of Spouse (if applicable) First Last Please list your children’s names and their ages:Addresses eye health and eyeglass prescriptions. 12. Contact Lens Examination: Enter InitialsThere are 3 levels; standard, complex, and custom. The fee for this service is separate from the comprehensive examination. 13. Contact Lens Assessment for individuals who are wearing Contact Lenses: Enter InitialsThis service (1) assesses the fit, positioning, power, corneal health, etc. with your contact lenses on, and then (2) assess your cornea and prescription (refraction) after removing your contact lenses. This additional testing is separate from a Comprehensive Examination. The fee for this assessment starts at $25.00. Brief Questionnaire1. Are you interested in getting eyeglasses today?YesNo2. Are you interested in getting contact lenses?YesNo3. Are you interested in contact lenses for occasional wear, such as sports or social events?YesNo4. Is your child having school-related problems or difficulty reading?YesNo5. Are you having vision problems after LASIK or PRK?YesNo6. Are you having vision problems after Brain injury? Crash, fall, etcYesNo7. Are you interested in learning about a Non-Surgical method to correct your vision?YesNo8. Do you wear:EyeglassesContact LensesBothNeither9. Do you see clearly at distance, for example, driving or watching TV?YesNoOnly if I wear my glasses.Only if I wear my contact lenses.10. Do you see clearly at near, for example reading, sewing, computer?YesNoOnly if I wear my glasses.Only if I wear my contact lenses.11. Do your eyes: Burn Itch Feel Dry Have Discharge Tear or Water Excessively 12. Do your eyes feel: Painful Achy Irritated as though there is something in your eyes 13. Do you ever see: Double Floaters Flashes of Light Sudden Blurred or Reduced Vision 14. Are you bothered by: Glare Smoke Allergies Bright Sunlight Artificial Lights Sinus Problems 15. Other symptoms / concerns?16. Occupation - what type of work do you do? Or is a student what at what level are you currently studying?17. At work, do you: Sit Stand Work Above Eye Level Use Computer Extensively 18. Hobbies - What types of things do you like to do?Example: Near work such as reading, crosswords, cards, crafts.19. What sports are you involved in?Example: Basketball, Golf, Swimming, Tennis, Racquetball, etc.
