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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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:______________________________