Patient registration 1 General information2 Eye history3 Medical history General InformationPlease Complete All of The Following:Full name:* First Middle Last Date of Birth* Age*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Cell Phone*Home PhoneWork PhonePatient Preferred NamePatient's Gender*MaleFemaleMarital Status*Please selectSingleMarriedDivorcedWidowedEmployer*Occupation*Alternate/Emergency Name*Alternate/Emergency Phone*By providing this information, you are consenting for us to contact you via these methodsA few questions to get to know you better1. How did you hear about Travers Lasik Vision Care*2. Have you been or do you plan to visit any other laser vision correction providers?*YesNo2b. How many?*3. What is your biggest concern about having vision correction surgery?*4. What problems, if any, are you currently having in your contacts or glasses?acts*5. What is motivating you to get rid of your glasses/contacts?*6. Will you be using funds from an employer sponsored flexible plan towards the future?*YesNoAre You Interested in Financing Your Procedure?*YesNo7. How soon would you like to have your laser vision correction?*ASAP1-4 weeks1-3 months> 3 months8. Have you read online or heard anything about LASIK that you would like the doctor to discuss?*YesNoPlease explain* Eye history1. Do you primarily wear*GlassesContact Lenses2. Who prescribed them?*3. How long have they been your provider?*4. I wear vision correction for:*ReadingDistanceBoth5. Do your glasses have prism in them?*Prism is used to correct double visionYesNo6. What type of contact lenses do you wear?*SoftToric for astigmatismRGP(None)Please provide an estimate of how old the prescription is for your contact lenses"*Number of years and/or months7. How many days per week do you wear Contact Lenses?*8. How Many Hours Per Day do you wear contact Lenses?*9. How many days per week do you sleep in your contact lenses?10. Have you ever had any prior surgery/laser treatments to your eye(s)*YesNoWhich eye?*What procedure*When?*Where?*Doctor?*11. Have you ever had an eye trauma?*i.e. Scratched cornea, something lodged in your eye, etc?YesNoPlease describe*12. Have you ever been diagnosed with an eye condition / disease?*i.e. Keratoconus, Sjögren's Syndrome, glaucoma, dry eye strabismus, lazy eye as a child?YesNoPlease describe*13. Are you currently using any eye medications?*YesNoPlease list them:* 14. Is there any family history of keratoconus, corneal diseases or blindness?*YesNoPlease describe and note the relation to the individual* Medical history1.Have you ever been treated for collagen, autoimmune, or immunodeficiency disease?*e.g. Arthritis (Rheumatoid not osteo), LupusYesNo1A. What disease?*1B. When were you diagnosed?*1C. Who is your treating physician?*1D. May we contact this doctor?*YesNo1E. Do you take any immunosuppressant medication for this condition?*YesNo1F. What medication?*2. Do you show signs of keratoconus ( a corneal disease) or have any other condition that causes thinning of your cornea?*YesNo3. Do you or have you ever been treated for herpes eye infections?*YesNo4. Do you or have you ever been treated for double vision?*YesNo5. Are you currently pregnant or nursing?*YesNo5A. How many times per day?*6A. When do you plan on stopping?*7. List all medical conditions you are currently being treated for: 8. List all surgeries you have had 9. Are You in Stable Health?*YesNo10. Do you or have you ever been treated for (check those that apply): Diabetes type 1 Diabetes type 2 Pace maker Stroke Seizures Hepatitis B or C Ulcers Cancer or tumor Heart disease High blood pressure Prostate disease Stomach problems Heart attack Neurological disorders Bleeding disorders Rheumatic disorders Sinus problems By-pass surgery Lung problems Liver disease HIV Kidney stones or infection 11. How long have you been suffering from diabetes type 2?*12. Are you using insulin?*13. What type of cancer/tumor?*MedicationsAre you allergic for any medications?*YesNoi.e. latex, iodine, valium, antibiotics, steroids, etcPlease list all medications that you are allergic to.* Are you currently taking any medication including over the counter?*YesNoPlease list all medications and dosages that you are currently taking:*Medication nameDosage Signature of patient*Date* Once you have completed your patient registration form, you have one more step by completing our Records Release Form.NameThis field is for validation purposes and should be left unchanged.