Cagle Eye Center

Cagle Eye Center Patient Registration
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Welcome

 

Welcome to Cagle Eye Center's web-based patient registration. We appreciate you helping us serve you more efficiently by registering online prior to your appointment. Our office is located at 402 Access Rd. in Fulton, Mississippi. If you have any questions, please feel free to contact us at (662)862-EYES. We look forward to your visit!

Office Location
Preferred Provider

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 -
Country
Address Type
Home Phone --
Cell Phone --
Cell Phone Carrier
Work Phone --
Work Phone Extension
Email @ I do not have an email account
Preferred Contact Method
Gender
Race
Ethnicity
Primary Language
Nickname
Marital Status
Employer Name
Occupation
Who shall we contact in case of an emergency?
First Name
Last Name
Home Phone --
Relationship
Work Phone --
Cell Phone --

 

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

 

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

 

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

 

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

 

MEDICAL RECORDS

 

Please list all systemic and ocular medications you are currently taking, including eye drops and over-the-counter drugs. Please also include any drugs you have previously taken that are considered "high-risk" to the eyes, such as plaquenil (hydroxychloroquine).

Medication Name Date Started (mm/dd/yyyy) Use
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Name of Allergy Reaction Severity Onset Type
Or Other:
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Date of Surgery (mm/dd/yyyy) Surgeon Name of Procedure
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Or Other:
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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
Other Eye Disease
Negative
Enucleation Both Eyes
Enucleation Left Eye
Enucleation Right Eye
Exophthalmos Both Eyes
Exophthalmos Left Eye
Exophthalmos Right Eye
Phthisis Bulbi Both Eyes
Phthisis Bulbi Left Eye
Phthisis Bulbi Right Eye
Blindness/ Vision Loss
Negative
Congenital
Corneal Scar
Enucleation
Injury Related
Legally Blind
Strabismus
Negative
Esophoria
Esotropia
Exophoria
Exotropia
Muscle Surgery
Amblyopia
Negative
Both Eyes
One Eye
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

 

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

 

Endocrine
Negative
Type 1 Diabetes - IDDM
Type 2 Diabetes - NIDDM
Gestational diabetes
Pre-diabetic
Adrenal Gland Disorders
Diabetes - Diet Controlled
Hyperthyroidism
Hypoglycemia
Hypothyroidism
Other:
Hematologic/ Lymphatic
Negative
Anemia
Blood Disorders
Enlarged Lymph Nodes
Hemachromatosis
Hemophilia
Leukemia
Lyme Disease
Lymphoma
Other:
Cardiovascular/ Heart
Negative
Angina
Arrhythmia
Bypass Graft
Bypass Surgery
Chest Pain
Congestive Heart Failure
Coronary Artery Disease
Cyanosis
Heart Disease
Heart Murmur
Heart Palpitation
High Blood Pressure Controlled
High Blood Pressure Uncontrolled
High Cholesterol
History Of Heart Disease
Irregular Heart Beat
Mitral Valve Prolapse
Pacemaker
Shortness Of Breath
Stent
Stroke
Valve Replacement
Other:
Neurological
Negative
Bell's Palsy
Cranial Nerve Palsy
Dizziness
Epilepsy
Involuntary Movement
Migraines
Paralysis
Seizures
Stroke
TIA
Vertigo
Other:
Ears, Nose, Throat
Negative
Chronic Colds
Chronic Sinusitis
Chronic Strep Infections
Dentures
Ear - Itching
Ear Infections
Ear Pain
Hearing Aid Both Ears
Hearing Aid Left Ear
Hearing Aid Right Ear
Hearing Loss Left Ear
Hearing Loss Right Ear
Mouth Sores
Nose Bleeds
Partial Hearing Loss Both Ears
Partial Hearing Loss Left Ear
Partial Hearing Loss Right Ear
Ringing In Ears
Runny Nose
Sinus Pain
Sinusitis
Sore Throat
Stuffy Nose
Other:
Respiratory/ Lungs
Negative
Asthma
Bronchitis
Chronic Bronchitis
Chronic Cough
Collapsed Lung Left
Collapsed Lung Right
COPD
Cough
Emphysema
Lung Cancer
Pleurisy
Pneumonia
Sarcoid
Shortness Of Breath
Tuberculosis
Other:
Stomach/ Intestines
Negative
Abdominal Pain
Bowel Cancer
Change In Appetite
Constipation
Crohn's Disease
Diarrhea
Difficulty Swallowing
Diverticulitis
Esophagitis
Frequency Of Bowel Movements
Gall Bladder Disease
Gastric Reflux
Heartburn
Hemorrhoids
Hepatitis Type A
Hepatitis Type B
Hepatitis Type C
Hernia
Indigestion
Irritable Bowel Syndrome
Jaundice
Nausea
Pancreatitis
Stomach Cancer
Ulcerative Colitis
Ulcers
Other:
Integumentary/ Skin
Negative
Basal Cell Carcinoma
Bruising
Changes In Color/ Pigmentation
Changes In Nails/ Hair
Dermatitis
Dryness
Eczema
Excessive Sweating
Itching
Lupus
Psoriasis
Skin Cancer
Skin Rash
Other:
Bones/ Joints/ Muscles
Negative
Arthritis
Back Pain
Bone Cancer
Cerebral Palsy
Gout
Joint Pain
Juvenile Rheumatoid Arthritis
Limited Range Of Motion
Multiple Sclerosis
Muscle Pain
Muscular Dystrophy
Neck Pain
Polymyalgia
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
Bladder Infections
Bladder Repair
Bladder Spasms
Cervical Cancer
Changes In Color Of Urine
Dialysis
Endometriosis
Frequent Urination
Incontinence
Kidney Failure
Kidney Infections
Kidney Stones
Kidney Transplant
Menopause Symptoms
Ovarian Cancer
Ovarian Cysts
Prostate Cancer
Recurrent Urinary Tract Infections
Renal Cancer
Renal Stricture
Sexually Transmitted Disease
Testicular Cancer
Uterine Cancer
Uterine Fibroids
Other:
Constitution
Negative
Chills
Fatigue
Fever
Insomnia
Sleeping All The Time
Sudden Weight Gain
Sudden Weight Loss
Weakness
Other:
Other
 
Other:
Past Medical Conditions
Details of Past Medical Conditions

 

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

 

  Mother Father Brother Sister 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

 

Please take a moment to review your information for accuracy. Once you have reviewed your information please be sure to click on the 'Submit' button and then make note of the confirmation number that is provided.


 

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