Cambridge Eye Group
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OFFICE FORM(S)
CAMBRIDGE EYE GROUP PATIENT REGISTRATION FORM
(TO BE COMPLETED ONLINE BEFORE VISIT):
Patient information:
*
Indicates required field
First Name
*
Last Name
*
Email Address
*
Phone #
*
Address
*
City
*
State
*
Zip Code
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Date of Birth (mm/dd/yyyy)
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Last Medical Exam
*
Primary care doctor
*
Last Eye Exam
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Guardian (if applicable)
*
Insurance Name (Type 'none' if you do not have insurance)
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Insurance #
*
Vision Plan Name
*
Vision Plan #:
*
MEDICAL HISTORY
Any allergies to medications
*
Yes
No
If yes, please list allergies to medications here in the box below:
*
List any medications you take:
*
Type 'none' if no medication is used
If need more space for medications please continue here:
*
List all major injuries, surgeries, and/or hospitalizations you have had:
*
Type 'none' if no surgeries or hospitalizations
If you need more space for major injuries, surgeries, or hospitalizations
*
Are your pregnant or nursing?
*
Yes
No
Do you wear correction?
*
Glasses
Contact Lens
Glasses and Contact Lens
Post ortho-keratology
Post lasik
None
Describe any details you would like us to know (Are you using soft lenses, RGPs, scleral lenses for example):
*
FAMILY HISTORY
Blindness
*
Yes
No
I don't know
Relationship to you
*
Cataract:
*
Yes
No
I don't know
Relationship to you
*
Crossed Eyes
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Yes
No
I don't know
Relationship to you
*
Macular Degeneration
*
Yes
No
I don't know
Relationship to you
*
Arthritis
*
Yes
No
I don't know
Relationship to you
*
Cancer
*
Yes
No
I don't know
Relationship to you
*
Diabetes
*
Yes
No
I don't know
Relationship to you
*
Heart Disease
*
Yes
No
I don't know
Relationship to you
*
High Blood Pressure
*
Yes
No
I don't know
Relationship to you
*
Kidney Disease
*
Yes
No
I don't know
Relationship to you
*
Lupus
*
Yes
No
I don't know
Relationship to you
*
Thyroid Disease
*
Yes
No
I don't know
Relationship to you
*
Any other conditions and relations to you:
*
SOCIAL HISTORY
I prefer to discuss social information with my doctor directly
*
Check this box
Do you drive?
*
Yes
No
Comments on driving:
*
Do you use tabacco products?
*
Yes
No
Alcohol Consumption?
*
Yes
No
REVIEW OF SYSTEMS
Constitutional:
Fever
*
Yes
No
Recent Weight Loss/Gain
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Yes
No
Integumentary:
Rash/Itching
*
Yes
No
New Moles/Growths
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Yes
No
Neurological:
Headaches
*
Yes
No
Migraines
*
Yes
No
Dizziness/Lightheadedness
*
Yes
No
Seizures
*
Yes
No
Numbness/Tingling Sensation
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Yes
No
Eyes:
Loss of vision
*
Yes
No
Blurred Distance Vision
*
yes
No
Blurred Near Vision
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Yes
No
Distorted Vision/Halos
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No
No
Loss of Side Vision
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Yes
No
Double Vision
*
Yes
No
Night Vision Problems
*
Yes
No
Color Vision Problems
*
Yes
No
Dryness
*
Yes
No
Mucous Discharge
*
Yes
No
Redness
*
Yes
No
Sandy or Gritty Feeling
*
Yes
No
Itching
*
Yes
No
Burning
*
Yes
No
Excess Tearing/Watering
*
Yes
No
Glare/Light Sensitivity
*
Yes
No
Eye Pain or Soreness
*
Yes
No
Chronic Eye Infection
*
Yes
No
Styes or Chalazion
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Yes
No
Flashes/Floaters in Vision
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Yes
No
Tired Eyes
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Yes
No
Endocrine:
Thyroid Problems
*
Yes
No
Other Gland Problems
*
Yes
No
Ears, Nose,
Mouth, Throat:
Allergies/Hay Fever
*
Yes
No
Sinus Congestion
*
Yes
No
Runny Nose
*
Yes
No
Post Nasal Drip
*
Yes
No
Chronic Cough
*
Yes
No
Dry Throat/Mouth
*
Yes
No
Respiratory:
Asthma
*
Yes
No
Chronic Bronchitis
*
No
No
Emphysema
*
Yes
No
Vascular/
Cardiovascular:
Diabetes
*
Yes
No
Heart/Chest Pain
*
Yes
No
High Blood Pressure
*
Yes
No
Vascular Disease
*
Yes
No
Gastrointestinal:
Diarrhea
*
Yes
No
Constipation
*
Yes
No
Genitourinary:
Kidney Stones
*
Yes
No
Difficult/Painful Urination
*
Yes
No
Incontinence
*
Yes
No
Bones/Joints/
Muscles:
Rheumatoid/Arthritis
*
Yes
No
Muscle Pain/Weakness
*
Yes
No
Joint Pain/Weakness
*
Yes
No
Lymphatic/
Hematologic:
Anemia
*
Yes
No
Bleeding/Bruising Problems
*
Yes
No
Allergic/Immunologic:
Eczema
*
Yes
No
Immunological Disease
*
Yes
No
Psychiatric:
Memory Loss/Confusion
*
Yes
No
Nervous/Panic Attacks
*
Yes
No
Insomnia
*
Yes
No
If you answered YES to any of the above or have a condition not listed, please explain and list medications
*
Specialty Clinic or Services Section (OPTIONAL: please skip to bottom to submit form if you are not seeking specialty care)
Select Specialty
*
Dry Eye Clinic
Myopia Control Clinic
Vision Rehabilitation and Trauma and Low Vision Center
Scroll down to specific section to fill out information
Dry Eye Clinic.
Dry Eye Disease is the most frequent reason the patients visit eye doctors. We are concerned that you may be suffering with this condition as well. Therefore, we ask that you take a few moments and thoughtfully complete the questions below.
Report the FREQUENCY of the dry eye symptoms. How many times are you experiencing the symptoms?
Dryness Grittiness or Scratchiness
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Never (0)
Sometimes (1)
Often (2)
Constant (3)
Soreness or Irritation
*
Never (0)
Sometimes (1)
Often (2)
Constant (3)
Burning or Watering
*
Never (0)
Sometimes (1)
Often (2)
Constant (3)
Eye Fatigue
*
Never (0)
Sometimes (1)
Often (2)
Constant (3)
Report the SEVERITY of the dry eye symptoms
Dryness, Grittiness or Scratchiness
*
Never (0)
Tolerable (1)
Uncomfortable (2)
Bothersome (3)
Intolerable (4)
Soreness or Irritation
*
Never (0)
Tolerable (1)
Uncomfortable (2)
Bothersome (3)
Intolerable (4)
Burning or Watering
*
Never (0)
Tolerable (1)
Uncomfortable (2)
Bothersome (3)
Intolerable (4)
Eye Fatigue
*
Never (0)
Tolerable (1)
Uncomfortable (2)
Bothersome (3)
Intolerable (4)
When was the most recent time you felt the above symptoms
*
Today
Within the Past 72 Hours
Within the Past 3 months
Do you use eye drops?
*
Yes
No
Did you use the eye drops today?
*
Did you use lotions or creams around the eye today?
*
Name of the eye drop?
*
Did you use makeup today?
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How long are they effective?
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Have you touched or rubbed your eyes today?
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Have you ever been diagnosed with Blepharitis
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Yes
No
Myopia Control Clinic
Nearsightedness (myopia) is a common vision condition diagnosed during a basic eye exam. For those who are nearsighted, objects that are farther away appear blurry. Myopia is caused by genetics, as well as other environmental factors. For instance, staring at any object for too long can cause the eye to elongate — it’s this elongation that leads to myopia.
Are you worried that you (or your child's) current glasses prescription will be going higher?
*
Yes
No
Which myopia control method are you interested in or would like more information about during your consultation?
*
Orthokeratology
Soft Lens Treatment
Atropine
Myopia control glasses
I don't know of any
Please check off any symptoms you or your child is currently experiencing
*
Staring too closely to a screen
Squinting at long distances
Rubbing yes frequently
Staring too closely at reading materials
Blinking excessivel
Having problems with daily activities
Unaware of distant objects
Holding books/table too close to the face
Complaining about eyesight or changes to eyesight often
Experiencing recurrent headaches
Vision Reabilitation, Trauma, and Low vision Center
There are many ways to help so that people with lost visual function or low vision can continue to do things that are important to them. Losing vision or visual function does not mean giving up activities, but it may mean learning new ways to do them.
Vision rehabilitation will help retrain your eyes to regain meaningful and functional use. We will help patients learn new strategies and find devices that can assist them.
Please explain your current symptoms or diagnosis leading to visual symptoms
*
Please List any goals that you may have that your current symptoms are preventing you from achieving
*
Submit
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OFFICE FORM(S)