Scituate Harbor Vision Source
Secure Form
Adult Registration
Step
1
of
2
50%
Welcome to the office of Jessica Crooker, Jung Chan, Melissa Andrade, and Rebecca Posner Doctors of Optometry
Name
*
First
Last
Date of Birth
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone
*
Mobile / Cell Phone
Email
Enter Email
Confirm Email
Name of Employer
Occupation
Medical Insurance
Medical Insurance ID#
Vision Insurance
Vision Insurance ID#
Referred By
Ocular History
Reason for examination
Last Eye Exam
When and where was your last eye exam?
Currently Wear Glasses?
Yes
No
When?
Near Tasks
Distance Tasks
Full-Time
Currently Wear Contacts?
Yes
No
Interested In Getting Contacts?
Yes
No
Type?
Are you interested in knowing more about laser vision corrections?
Yes
No
What problems are you currently having with your eyes?
Cataracts
Crossed Eye
Glaucoma
LASIK or RK
Lazy Eye
Macular Degeneration
Retinal Detachment
Blurry Vision (near or far)
Burning
Discharge
Double Vision
Dryness
Excess Tearing/Watering
Eye Infection
Eye Pain or Soreness
Floaters or Spots
Halos
Headaches
Itching
Light Flashes
Light Sensitivity
Redness
Sandy or Gritty Feeling
Other
Other
Please explain above
Do you have any of the following eye conditions?
Amblyopia / Lazy Eye
Blindness
Cataracts
Glaucoma
Retinal Detachment
Macular Degeneration
Nystagmus
Retinal Disease
Diabetic Eye Disease
Other
Other
Medical History
Primary Care Physician
Last Medical Exam
Please list any current medications
Please list any allergies to medications
Please list any major surgeries or injuries
Are you pregnant or nursing?
Yes
No
Approximate Weight
Approximate Height
Problem (example)
Allergies (medications, antibiotics, pollen, mold)
Yes
No
Explain
Cardiovascular / Heart Problems (hypertension)
Yes
No
Explain
Constitutional (excessive weight loss, dizziness)
Yes
No
Explain
Endocrine Problems (thyroid disease, diabetes)
Yes
No
Explain
Gastrointestinal Problems (hepatitis, colitis)
Yes
No
Explain
Urinary Problems (sexually transmitted disease)
Yes
No
Explain
Ear/Nose/Throat Problems (hearing loss, dry mouth)
Yes
No
Explain
Blood Disease (anemia, temporal arteritis, sickle)
Yes
No
Explain
Immunological (lyme disease, HIV, AIDS, herpes)
Yes
No
Explain
Skin (psoriasis, rashes, dermatitis, rosacea)
Yes
No
Explain
Musculoskeletal Problems (rheumatoid arthritis)
Yes
No
Explain
Neurological (seizures, migraines, dyslexia)
Yes
No
Explain
Psychiatric / Social Problems (depression, ADD)
Yes
No
Explain
Breathing Problems (asthma, sarcoidosis)
Yes
No
Explain
Cancer (colon cancer, melanoma)
Yes
No
Explain
Other
Family History
Does anyone in your immediate family have any of the following?
Amblyopia / Lazy Eye
Blindness
Cataracts (before 40 years old)
Macular Degeneration
Retinal Detachment
Eye Turn / Strabismus
Glaucoma
Other Eye Disease
Color Blindness
Genetic / Familial Disorders
Cancer
Diabetes
Elevated Cholesterol
High Blood Pressure / Heart Problems
Thyroid Disease
Other
Other
Please list your family members with the above circled conditions
Social History
Do you drive?
Yes
No
Do you consume alcohol?
Yes
No
Do you use tobacco products?
Yes
No
Do you consume narcotics?
Yes
No
Living status?
Single
Married
Widowed
Living Alone
With Family
Assisted Living
Hobbies?
Sports?
I authorize payment of benefits directed to Dr. Jessica Crooker, Dr. Jung Chan, Dr. Melissa Andrade, and Dr. Rebecca Posner for services rendered. I also authorize release of any medical information that may be required in determination of such benefits. I understand that some services may require approval of my primary care physician for coverage and that, if I don't obtain that approval, I am financially liable for the services. I understand that my insurance carrier may not cover some services and products and benefit information does not constitute approval of payment. Deductibles & fee not paid by my insurance carrier will be my responsibility. I acknowledge that I received a copy of Dr. Jessica Crooker, Dr. Jung Chan, Dr. Rebecca Posner, and Dr. Melissa Andrade's "NOTICE OF PRIVACY, HIPAA" policy.
*
Yes
No
Signature
Date
mm/dd/yyyy
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.
