Download Patient Demographics Glasses History Contact Lenses History

Welcome to our office!
Reason for today’s visit:____________________________________________________________________________
When was your last eye exam?______________________________________________________________________
Are you planning on new glasses today?
Y
N
Do you wear contact lenses? Y N
If not, are you interested in trying contacts today?
Maybe
Y
N
Maybe
Are you interested in learning more about Laser Vision Correction?
Y
N
Maybe
Patient Demographics
Please circle:
Mr.
Mrs.
Ms.
Miss
Dr.
Male
Female
______________________________________________________________________________________________
First Name
MI
Last Name
Preferred Name
______________________________________________________________________________________________
Mailing Address
City
State
Zip Code
______________________________________________________________________________________________
Cell Phone
Home Phone
Daytime Phone
______________________________________________________________________________________________
E-Mail Address
Date of Birth
Social Security Number
______________________________________________________________________________________________
Employer
Occupation
What is the best way to contact you?
Email
Cell Phone
Daytime Phone
Text
Whom do we thank for referring you to our office?_____________________________________________________
If not referred by a patient, how did you hear about our office?___________________________________________
Glasses History
Do you currently wear glasses: Y
Glasses being worn now:
Do you wear sunglasses?
Y
N
N
Part-time
Full-Time
Single Vision
Bifocals
If yes, are your sunglasses your most recent prescription? Y/N
Contact Lenses History
Do you currently wear contact lenses? Y/N
Hours per day:_____________ Days per week:___________________
Brand or prescription you are currently wearing?________________________________________________________
If not wearing contacts now, have you tried them in the past? Y/N Reason for stopping:_________________________
________________________________________________________________________________________________________
Social History
Do you have any hobbies that require special glasses or contacts?__________________________________________
Use of Alcohol:
None___
Social use only___
1-2 drinks daily___
Above average use___
Use of Tobacco:
None___
Former Smoker___
Light Smoker___
Average Smoker___
Patient Ocular History
Blurred Distance Vision
Blurred Near Vision
Cataracts
Glaucoma
Macular Degeneration
Dryness
Sandy/Gritty Feeling
Redness
Burning
Excess Tearing/Watering
Itching
Flashes of Light
Floaters
Retinal Detachment
Double Vision
Glare/Light Sensitivity
Problems driving at night
Fluctuating Vision
Mucous Discharge
Headaches
Amblyopia/Lazy Eye
Ocular Surgery:_____________________________ Year______ Which Eye?________ Dr.__________________
Ocular Surgery:_____________________________ Year______ Which Eye?________ Dr.__________________
_________________________________________________________________________________________________________
Patient Medical History
High Blood Pressure
Diabetes
Thyroid (high or low)
Elevated Cholesterol
Congestive Heart Failure
Stroke
Renal Disease
Migraines
Acne Rosacea
Lupus
Arthritis
Rheumatoid Arthritis
Bell’s Palsy
Multiple Sclerosis
Parkinson’s Disease
Seizures
Alzheimer’s
Depression
Sinusitis
Asthma
COPD
Emphysema
Cancer (type)
List any other medical conditions you are being treated for:____________________________________________
Are you pregnant? Y/N
Are you breastfeeding? Y/N
Family Physician:________________________________________ Date of Last Physical Exam:_______________
_______________________________________________________________________________________________________
Current Medications:
____________________________________________________________________________________________
____________________________________________________________________________________________
Allergies to Medications: ________________________________________________________________
________________________________________________________________________________________________________
_________________________________________________________________________________________________________
In order to file any insurance claims for you, we must copy ALL insurance cards at the time of your visit.
If we are filing insurance for you today, the following questions must be answered:
Employment Status:
Marital Status:
Employed FT
Single
Employed PT
Married
Not Employed
Divorced
Student
Widowed
Retired
Guarantor (Account Responsibility) if patient is a minor:
_______________________________________________________________________________________________________
Full Name
Relationship to Patient
_______________________________________________________________________________________________________
Daytime Phone Number
Social Security Number
Date of Birth
Vision Insurance Name:_____________________________________________________________
Medical Insurance Name:____________________________________________________________
Additional Insurance Name:__________________________________________________________
Are you the policy holder? Y/N
If no, name of the policy holder:____________________________________________________________________
______________________________________________________________________________________________
Policy Holder’s Date of Birth
Social Security Number
Relationship to patient
________________________________________________________________________________________________________
INSURANCE:
I hereby authorize payment of my medical and surgical insurance benefits to Amarillo Family Eyecare. I agree/understand I am
financially and fully responsible for payment and any charges, whether paid for or denied by said insurance. If co-payments
and/or deductibles are designated by my insurance company or health plan, I agree to pay them to Amarillo Family Eyecare at
the date of service. I authorize Amarillo Family Eyecare to release any information required to process any and all claims for
reimbursement on my behalf. A copy of the authorization may be used in place of the original.
Signature:___________________________________________
Date:______________________________
ACKNOWLEDGEMENT OF RECEIPT:
I acknowledge that I received a copy of Notice of Privacy Practices from Amarillo Family Eyecare.
Print Name:____________________________________________________________________________________
Signature:___________________________________________
Date:______________________________