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for Dr. Allan J. Panzer, O.D., Houston, Texas

Dr. Allan J. Panzer, O.D.
Therapeutic Optometrist

713-664-4760
DrAllanPanzer.com




4760 Beechnut (at Loop 610)
Houston, Texas, 77096
Patient Registration Form Title

If you do not yet have an appointment, please call our office at (713) 664-4760 to schedule an appointment before submitting your information to us.
Patient Information
Last Name:
First Name: MI Title
Appointment Date:      *   * *
Male     Female What is your 'nickname', or by what name do you prefer to be called?
Address:
City: Zip:
Date of Birth:      *   * * Age:
Social Security #:
- - D.L.#
Personal Phone:
() Daytime Phone: () Ext.#
Email:
Retype Email: Occupation:
Employer:
Address: How Long?:
Student:
Yes No If Yes - City: If Yes -
Name of nearest relative not at same address:   Relationship:
Address: City: State/Country: Phone: ()
Marital Status: Minor Single Married Life Partner Legally Separated Divorced Widowed

Responsible party
The patient is the responsible party (skip this section).
The patient is not the responsible party (complete this section).
Last Name:
First Name: MI Title
Address:
City: Zip:
Date of Birth:      *   * * Age:
Social Security #:
- - D.L.#
Personal Phone:
() Daytime Phone: () Ext.#
Email:
Retype Email: Occupation:
Employer:
Address: How Long?:
Name of the nearest relative not at same address: Relationship:
Address: City: State/Country: Phone: ()
Relationship to the patient? Please state relationship if 'other'

Please list two people who could be notified in case of an emergency
1Last Name:
First Name: Relationship:
Address:
City: Zip:
Personal Phone:
() Daytime Phone: () Ext.#
2Last Name:
First Name: Relationship:
Address:
City: Zip:
Personal Phone:
() Daytime Phone: () Ext.#

How were you referred to us?
Cellspacer Family or Friend Name: Insurance Company Name:
Cellspacer Family Physician Name: City: Phone: ()
Cellspacer Another Physician Name: City: Phone: ()
Cellspacer Attorney Name: City: Phone: ()
Cellspacer Received Mailing Television Radio Newspaper Internet Yellow Pages Other

Please list all insurances below, both vision and medical.
Also, please remember to bring all insurance cards with you to your appointment so that we can make a copy of them.
The social security number of the Policyholder is not a requirement for the completion of this form, but we will be unable to verify your insurance coverage without it. This form uses the highest level of security available on the web, but if you would rather give it to us by phone, call us at (713) 664-4760 and ask for the appointment desk.

I have insurance I do not have insurance

Primary Insurance Information Secondary Insurance Information
Insurance Company Name:
Insurance Company Name:
Address:
Address:
City
City
State
State
Phone Number listed on card for verification of benefit eligibility:
()
Phone Number listed on card for verification of benefit eligibility:
()
Name of Insured (Policyholder)
Name of Insured (Policyholder)
ID / Policy / Subscriber Number
ID / Policy / Subscriber Number
Group or Employer Name:
Group or Employer Name:
Group Number
Group Number
Policyholder's D.O.B.
Policyholder's D.O.B.
Soc Sec# of Insured (Policyholder)
- -
Soc Sec# of Insured (Policyholder)
- -
Patient's Relation to Insured:
Patient's Relation to Insured:
Although our main focus is on your eyes (no pun intended!), your eyes are a part of your entire body. Your lifestyle, eyhnic origin, health problems that you may have, and medications that you may be taking -- including OTC, vitamins, and holistic / herbal preparations -- can have an important inter-relationship with the condition of your eyes and your prescribed eye care.

We want to give you the best eye care available, so we thank you for answering the following questions. Your answers are for our records only and are confidential.

CellspacerGeneral Health
Please list everything that you are currently taking. Include prescription, non prescription (over-the-counter), aspirin, vitamin supplements and holistic or herbal preparations.
-- or --
Cellspacer Not taking anything.
Tell us if you have any allergies (such as latex, pollen, drugs, food, food additives or insect stings).
-- or --
Cellspacer No known allergies.
Describe the purpose of this appointment..
-- or --
Cellspacer The purpose of this appointment is a routine eye exam.
Are you currently under the care of a physician?Cellspacer If 'Yes' Physician's Name: CellspacerPhone: ( )
What was the approximate date of your last physical exam?Cellspacer
Name of Physician: Cellspacer City: Cellspacer CellspacerPhone: ()
What is your ethnicity? Asian Black Caucasian Hispanic Other
Do you drink alcohol? No Occasionally 1/day 2-3/day 4+/day
Do you smoke? Never did Used to, but quit 1/2 pack/day 1 pack/day 1+ pack/day
Do you exercise? No Occasionally Every Day Several times/wk. Once a week
What types of exercise? walk Cellspacer run / jog Cellspacer swimCellspacer golf Cellspacer active sports Cellspacer yoga Cellspacer gymnastics / aerobics

CellspacerEye Health I
Do you currently wear glasses? Yes No Full Time Part Time Distance Near Reading
What type of glasses do you own?  Single Vision Bifocals Safety Glasses Backup Glasses
Progressive Trifocals Sports Glasses Other
Cellspacer Do you use a Computer?CellspacerApprox. Hours per day: CellspacerApprox. distance from computer: in.
Please describe any problems that you are having with your eyeglasses.

CellspacerEye Health II - Please check all below that apply to you. Checked boxes indicate that the answer is 'Yes'
Do you frequently lose your place when reading unless you use a straight edge or your finger as a guide?
Cellspacer Do you have problems with glare?
Do you have problems with night vision?
Do you have styes often?
Are you allergic to Nickel (eg; jewelry or eyeglass frames discoloring your skin)?
If you currently wear eyeglasses, are there certain times when you would prefer not to?
If you currently wear eyeglasses, does your spare pair have your most recent prescription?
Do you wear sunglasses that provide 100% UV (ultra-violet) protection?
Do you wear prescription sunglasses (current prescription)?
Do you have any personal history of cardiac or vascular health problems?
Do you have high blood pressure?
Does (did) anyone in your family have high blood pressure?
Do you have a thyroid condition?
Does (did) anyone in your family have thyroid problems?
Are you color blind or do you have some degree of color vision deficiency?
Does (did) anyone in your family have color vision deficiency (color blindness)?
Do you have diabetes?
Does (did) anyone in your family have diabetes?
Have you ever been treated for glaucoma?
Does (did) anyone in your family have glaucoma?
Have you ever had cataracts?
Does (did) anyone in your family have cataracts?
Cellspacer
CellspacerDo you suffer from any of the following? Please check all that apply.
Cellspacer Distance Vision Blur Seeing Flashes Dry Eyes
Near Vision Blur Distorted Vision (Haloes) Itching Eyes
Middle Vision Blur Glare / Light Sensitivity Red Eyes
Double Vision Loss of Side Vision Eye Pain / Soreness
Headaches Crossed Eyes Tearing / Discharge
Cellspacer
CellspacerContact Lenses:
Do you currently wear contact lenses? Yes
How long have you been wearing contacts? Less than 5 Ys. 5 Yrs. + 10 Yrs. +
Have you ever tried wearing contact lenses and stopped? Yes
If you answered 'Yes' above, what was your reason for stopping?
Are you interested in using contact lenses to change or enhance your eye color? Yes
If you wear contact lenses, do your backup eyeglasses have your correct prescription? Yes

Answer questions (a) through (f) below only if you currently wear contact lenses
Cellspacer  a. What type or brand of contacts do you wear?
 b. How old are your current lenses?
 c. How often do you replace or dispose of your contact lenses?
 d. What brand of solution do your lenses soak in overnight?
 e. What is your typical wearing schedule? Hrs/day Days/wk -- or no regular schedule
 f. Please describe any problems you are having
     with your contact lenses.

CellspacerEye Health III
Have you ever had an injury to either of your eyes? Yes
If you checked 'Yes', please use the text box to tell us about it.
If you have ever had any type of eye surgery, please give us the information below.Cellspacer
Type of surgery: Month and Year: Doctor: Phone: ( )
Type of surgery: Month and Year: Doctor: Phone: ( )

Cellspacer CellspacerI would like to be evaluated for refractive laser surgery (LASIK).
Cellspacer CellspacerI would like to be evaluated for a NON-surgical method to correct my vision (CRT).
What was the approximate month and year of your last eye exam?
Where did you get the exam?
Use this space for additional comments or information -- or if you have a specific issue concerning your eye health that you want to discuss with the doctor when you come in for your appointment.
Do you have a hobby or special interest? What do you like to do in your spare time?
We like to keep you informed -- and we enjoy remembering you on special occasions:
May we email you approximately twice yearly to inform you of the latest news in the area of eye health? Yes No
May we send you seasonal and birthday greetings via email? Yes No
(Your email address is never shared with anyone else. It will be used only for the purposes listed above.)
Please scroll up and review your responses before submitting this information.
Thank you for choosing us for your eye care. We look forward to seeing you!