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BOYD EYE CARE

MANSFIELD TEXAS

Patient Registration Paperwork

Please fill out the following form to help us understand your physical condition.

Personal Information Section

Prefix

First Name

Last Name

Address

ZIP Code

State

Country

Preferred Phone Number

Date of Birth

City

Preferred Language

Email Address

Gender

Last 4 of SSN#

Ethnicity

Race

Marital Status

Employment Status

Occupation

Employer

How Did You Find Us

Preferred Communication Method

Eye History Section

Choose any Current conditions you have

I stopped wearing glasses

I stopped wearing contact lenses

Headaches

Glare or Light Sensitivity

Tired Eyes

Amblyopia or Laazy Eye

Burning

Dryness

Watery Eyes

Eye Pain or Soreness

Foreign Body Sensation

Infection of Eye or Lid

Itching

Mucous Discharge

Drooping Eyelids

Redness

Sandy or Gritty Feeling

Strabismus or Cross Eye

Blurred Vision at Distance

Blurred Vision close up

Haloes

Double Vision

Floaters or Spots

Fluctuating Vision

Loss of Vision

Loss of Side Vision

Glasses or Contacts History Section

Do you wear Glasses

Do you wear Contact Lenses

Medical History Section

When approximately, was your last eye exam

Where did you get your last eye exam

Who is your Primary Care Physician

Do you drink alcohol

When approximately was your last physical exam

Do you use tobacco

List all medical conditions you have ever had (Diabetes, High Blood Pressure, Arthritis, etc)

Please List all eye conditions you have ever had (Glaucoma, Cataract, Wandering,Retinal Detachment)

Please list any medical or eye conditions than run in your family or close relatives. Diabetes, Glaucoma, etc)

List any surgeries you have had

List any prescription drugs and over the counter medications you take and for what conditions

Please list all drug allergies you have

Choose any current conditions you suffer from

Chronic Fever, unexpected weight loss or gain, fatigue

Ear, Nose, Throat issues : Hearing Loss, Sinus Problems, Sore Throat

Heart Problems : Chest Pains, irregular heart beat, swelling of feet, cold hands or feet

Respiratory problems : Shortness of breath, wheezing, coughing

Gastrointestinal problems : Heartburn, abdominal pain, diarrhea, vomiting

Genitourinary problems : Painful urination, blood in urine, sex organ problems

Musculoskeletal problems : Muscle aches, joint pain, swollen joints

Skin problems : Rashes, excessive dryness, growths or lumps

Neurological problems : Numbness, weakness, headaches, “blackouts"

Psychiatric problems : Depression, anxiety

Endocrine problems : Frequent urination, thirst, feeling hot or cold all the time

Blood/Lymph problems : Bruising, weakness, unusual paleness, swollen glands

Immune problems : Frequent infections, allergic reactions to foods, dust, pollens

Primary Insurance Section

Insurance Company Name

Insurance Company Phone Number

Address

ZIP Code

State

City

Insurance Person's Name

Insurance Identification Number

Insurance Group Number

Insured Date of Birth

Patient's Relationship to Insured

Secondary Insurance Section

Do you have secondary insurance

I declare that the info I’ve provided is accurate & complete

I have read and agree to the Privacy Policy

View Privacy Policy

Thanks for submitting!

© 2019-2023 by Boyd Eye Care & Texas Best EyeCare

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