Baltimore Pediatric Contact Lenses :: Westminster, Clarksville, Eldersburg, MD

New Patient Registration Form

Patient's Name:

First Name	Sex	M F
Middle	Age
Last Name	Date of Birth
Nickname, if any	Home Phone
Address	Cell Phone
City	State	Zip
Does patient now wear glasses or contacts? If Yes, please remember to bring them with you.	Yes	No
Reason for this visit to our office?

Insurance Information:

Patient's Social Security Number
Insurance Company		Insurance I.D. No.

For Pediatric Patients ONLY:

Are you the natural parents of this child?	Yes No
Mother:
First Name	Address
Last Name	City
Maiden Name	State	Zip
Home Phone	Work Phone
Father:
First Name	Address
Last Name	City
Middle	State	Zip
Home Phone	Work Phone

As a parent, are you an active member of any parent or child related group? YES NO
Name of Group or Organization:	Who Belongs?:	Mother	Father

Patient's Pediatrician or Regular Physician:

First Name	Phone
Last Name
Address	City
Address	State	Zip
Did the above doctor refer you to us?	Yes	No
If No, Name and Address of doctor or person who referred you:
Name
Address

Please list all brothers or sisters of this patient (check who has been seen at our office):

Does anyone in patient's family have a history of any of these eye conditions?

Strabismus (crossed eyes)	Yes	No	Relationship:
Amblyopia (lazy eye)	Yes	No	Relationship:
Cataracts	Yes	No	Relationship:
Glaucoma	Yes	No	Relationship:
Color Blindness	Yes	No	Relationship:
Other eye diseases	Yes	No	Relationship: Please specify:

Who in the family wears glasses or contact lenses?

Mother	Father	Brother Sister	Brother Sister
Reason: Myopic (near-sighted) Hyperopic (far-sighted) Astigmatism	Reason: Myopic (near-sighted) Hyperopic (far-sighted) Astigmatism	Reason: Myopic (near-sighted) Hyperopic (far-sighted) Astigmatism	Reason: Myopic (near-sighted) Hyperopic (far-sighted) Astigmatism

For Pediatric Patients ONLY - Patient's Birth-Related History:

Weight at birth	lbs:	oz.
Was patient premature?	NO	YES	If yes, by how many weeks?
Did patient receive oxygen therapy at birth?	NO	YES	If yes, for how long?
Did patient have any infections or other medical problems at birth?	NO	YES	If yes, please explain:
Did patient have jaundice?	NO	YES	If yes, was patient placed under light therapy? No Yes If yes, for how long?
Did patient have any respiratory problems at birth?	NO	YES	If yes, please explain:
Did patient have any eye problems at birth?	NO	YES	If yes, please explain:

All Patients - Medical History:

Is patient taking any medication at this time?	NO	YES	If yes, name of medication: Reason for taking:
Does patient have any seasonal allergies (eg.hay fever)?	NO	YES	If yes, what kind?
Has patient ever had an allergic reaction (eg. food, bees)?	NO	YES	If yes, what kind?
Has patient ever had any unfavorable reactions to medications	NO	YES	If yes, name of medication: Type of reaction:
Has patient ever had surgery?	NO	YES	If yes, what kind?
Was patient ever hospitalized for medical problems?	NO	YES	If yes, what kind?
Are there any hereditary medical problems in patient's family?	NO	YES	If yes, what kind?

Patient's Complaints:

Does patient complain of any visual disturbances when reading? (Blurry vision, double vision, tearing, aching eyes)	NO	YES	If yes, Please explain:
Does patient complain of frequent headaches?	NO	YES	If yes, Please explain:

Developmental History and Learning Problems:

Hearing deficiencies	Delayed growth	Hyperactivity
Speech deficiencies	Developmental delays	Other Learning disabilities
Emotional difficulties	Attention deficit	Other:
Behavioral difficulties	Dyslexia (reading disability)	Other:

Additional Patient Information:

Additional Comments:

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Thank you for providing the information requested. It will help us to serve you better and save time when you arrive at our office.

Dankner-Fiergang Eye Associates offers Pediatric Contact Lenses in Maryland.
Pediatric Contact Lenses in Baltimore, Westminster, Clarksville, Eldersburg, Maryland, MD