Ankeny Family Vision Center

Ankeny Family Vision Center Patient Registration
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Welcome

 

Welcome to Ankeny Family Vision Center’s Online Patient Registration. We appreciate your effort in completing these forms prior to your appointment. Please ensure that you disable any pop-up blockers. You are enabling our professional staff to have the ability to serve you better with the most accurate and comprehensive care. If you have any questions regarding these forms, please contact our office at 515.964.1671.

Preferred Provider & Office Location

Office Location
Preferred Provider

Patient Information

First Name
Middle Initial
Last Name
Suffix
Date of Birth //MM/DD/YYYY
Social Security Number --Numbers only, no special characters
Salutation
Street Address
City
State
Zip -
Home Phone --
Cell Phone --
Work Phone --
Work Phone Extension
Email @ I do not have an email account
Race
Ethnicity
Primary Language

 

Account Responsible Information

Click here to copy information from the Patient Information Section

First Name
Middle Initial
Last Name
Date of Birth //MM/DD/YYYY
Social Security Number --Numbers only, no special characters
Salutation
Street Address
City
State
Zip -
Home Phone --
Work Phone --
Work Phone Extension
Email @ I do not have an email account
Relationship to Patient

 

Medical Insurance Information

Click here to copy information from the Patient Information Section

Click here to copy information from the Account Responsible Section

Insurance Company Name
Or Other:
Carrier Street
Carrier City
Carrier State
Carrier Zip -
Insured Person First Name
Last Name
Middle Initial
Suffix
Insured Date of Birth //MM/DD/YYYY
Salutation
Street Address
City
State
Zip -
Home Phone --
Sex
Insurance ID #
Group Number
Group Name
Employer/ School
Relationship

Insurance Company Name
Or Other:
Carrier Street
Carrier City
Carrier State
Carrier Zip -
Insured Person First Name
Last Name
Middle Initial
Suffix
Insured Date of Birth //MM/DD/YYYY
Salutation
Street Address
City
State
Zip -
Home Phone --
Sex
Insurance ID #
Group Number
Group Name
Employer/ School
Relationship

Insurance Company Name
Or Other:
Carrier Street
Carrier City
Carrier State
Carrier Zip -
Insured Person First Name
Last Name
Middle Initial
Suffix
Insured Date of Birth //MM/DD/YYYY
Salutation
Street Address
City
State
Zip -
Home Phone --
Sex
Insurance ID #
Group Number
Group Name
Employer/ School
Relationship

 

Vision Insurance Information

Click here to copy information from the Patient Information Section

Click here to copy information from the Account Responsible Section

Insurance Company Name
Or Other:
Carrier Street
Carrier City
Carrier State
Carrier Zip -
Insured Person First Name
Last Name
Middle Initial
Suffix
Insured Date of Birth //MM/DD/YYYY
Salutation
Street Address
City
State
Zip -
Home Phone --
Sex
Insurance ID #
Group Number
Group Name
Employer/ School
Relationship

 

Referral Information

Doctor Referral
Patient Referral
Newspaper
Internet Search
Or Other:
Other
Drive By/Signage
 Word of Mouth
 
Other:

 

MEDICAL RECORDS

 

Medications

Medication Name Date Started(mm/dd/yyyy) Use
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Allergies

Name of Allergy Reaction Severity Onset Type
Or Other:
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Surgeries

Date of Surgery(mm/dd/yyyy) Surgeon Name of Procedure
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Or Other:
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Ocular History

Click here to mark all items as "Negative"

Glaucoma
Negative
Glaucoma Suspect
Glaucoma Unspecified
Narrow Angle Glaucoma
Open Angle Glaucoma
Cataracts
Negative
Beginning Cataracts
Cataract Removed Both Eyes
Cataract Removed Left Eye
Cataract Removed Right Eye
Macular Degeneration
Negative
Macular Pucker (Epiretinal Membrane)
Previous Laser Treatment
Previous Treatment by Injection
Previously Diagnosed
Eye Injury
Negative
Corneal Foreign Body Left Eye
Corneal Foreign Body Right Eye
Eye Trauma
Penetrating Injury
Retinal Disease
Negative
Diabetic Retinopathy
Macular Degeneration
Macular Hole
Retinal Detachment
Retinal Tears
Strabismus
Esotropia
Exotropia
Muscle Surgery
Amblyopia
Negative
Treatment Management: Eye Muscle Surgery
Treatment Management: Glasses
Treatment Management: Patching
Treatment Management: Pharmacological
Treatment Management: Vision Therapy
Ocular Complications Related to Diabetes YesNo
Dry Eye
Negative
Mild
Moderate
Severe
Wear Glasses or Contacts
Other

 

General History

Who is your Primary Care Physician?
Last Visit to PCP
Reason for Visit to PCP
Last Eye Exam //MM/DD/YYYY
Last Eye Exam with (Dr or Office)
Do you work on a computer? YesNo
Hours per day

 

Health Review

Click here to mark all items as "Negative"

Endocrine
Negative
Adrenal Gland Disorders
Diabetes Type I
 Diabetes Type II
Hyperthyroidism
Hypoglycemia
 Hypothyroidism
Other:
Hematologic/ Lymphatic
Negative
Anemia
Blood Disorders
 Enlarged Lymph Nodes
Leukemia
Lyme Disease
 Lymphoma
Other:
Cardiovascular/ Heart
Negative
Bypass Surgery
Congestive Heart Failure
Coronary Artery Disease
 Heart Disease
High Blood Pressure Controlled
High Blood Pressure Uncontrolled
High Cholesterol
 History Of Heart Disease
Stroke
Other:
Neurological
Negative
Bell's Palsy
Cranial Nerve Palsy
Epilepsy
 Migraines
Paralysis
Seizures
Stroke
 TIA
Vertigo
Other:
Ears, Nose, Throat
Negative
Chronic Colds
Chronic Sinusitis
 Chronic Strep Infections
Sinus Pain
Sinusitis
 Sore Throat
Other:
Respiratory/ Lungs
Negative
Asthma
Bronchitis
COPD
 Cough
Emphysema
Lung Cancer
Pneumonia
 Sarcoid
Shortness Of Breath
Tuberculosis
Other:
Stomach/ Intestines
Negative
Abdominal Pain
Bowel Cancer
Crohn's Disease
Gall Bladder Disease
 Heartburn
Hepatitis Type A
Hepatitis Type B
Hepatitis Type C
Irritable Bowel Syndrome
 Pancreatitis
Ulcerative Colitis
Ulcers
Other:
Integumentary/ Skin
Negative
Basal Cell Carcinoma
Bruising
 Dermatitis
Dryness
Eczema
 Lupus
Psoriasis
Skin Cancer
Other:
Bones/ Joints/ Muscles
Negative
Arthritis
Back Pain
Bone Cancer
 Gout
Joint Pain
Juvenile Rheumatoid Arthritis
Multiple Sclerosis
 Muscle Pain
Muscular Dystrophy
Neck Pain
Rheumatoid Arthritis
Other:
Allergic/ Immunologic
Negative
Allergy Shots
 HIV
Immune Disorder
 Lupus
Seasonal Allergies
Other:
Psychiatric
Negative
Depression
 Panic Episodes
Stress
 
Other:
Genitals/ Kidney/ Bladder
Negative
Cervical Cancer
Kidney Stones
 Ovarian Cancer
Prostate Cancer
Recurrent Urinary Tract Infections
 Sexually Transmitted Disease
Other:
Constitution
Negative
Fatigue
 Fever
Insomnia
 
Other:
Other
 
Other:
Past Medical Conditions
Details of Past Medical Conditions

 

If Diabetic

When were you diagnosed as diabetic?
Blood Sugar
Date of Last Blood Sugar //MM/DD/YYYY
Self Monitoring Blood Sugar YesNo
HbA1C .
HbA1C Time //MM/DD/YYYY

 

Social History

Do you smoke?
Do you drink alcohol?
Recreational Drug Use
Occupation
Hobbies

 

Family History

  Sister Mother Father Brother Paternal Grandmother Maternal Grandmother Paternal Grandfather Maternal Grandfather
Family History of Glaucoma
Cataracts
Macular Degeneration
Eye Injury
Retina Disease
Other Eye Disease
Strabismus
Amblyopia
Blindness/ Vision Loss
Diabetes
Cancer
Heart Disease
Other Family History

 

Review and Submit


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