Download History – Please complete form and fax to 214-265

History – Please complete form and fax to 214-265-1189 or bring with day of exam. Thank You
Social Security # Exam Date
Name(s) of Insurance
Name:
Address:
City: .
State:
Zip:
Phone(s) - Cell
Work
Email
Date of Birth:
Height; . ft
Race:
inches
Ethnicity:
Referred to us by:
Eye Doctor:
Weight in lbs
Blood Pressure:
Age:
(example) 120/80
Language:
Primary Care Physician:
Date of last eye exam:
Reason for today’s visit:
Patient Medical Eye History: Check those that apply to you (the patient):
☐Cataract Surgery ☐Cone Dystrophy ☐Crossed Eyes ☐Diabetic Retinopathy
☐Double Vision ☐Drooping Lid (Ptosis) ☐Dry Eye ☐Eye Injury ☐Glaucoma ☐Lasik
☐Lazy Eye (Amblyopia) ☐Loss of Side Vision ☐Macular Degeneration ☐Nystagmus
☐Ocular Albinism ☐Optic Atrophy ☐Retinitis Pigmentosa ☐Retinal Detachment
☐Stargardt’s ☐Traumatic Brain Injury ☐Other Eye Condition Other
Family History – Check if blood relative(s) have had the following conditions:
☐Cataracts ☐Macular Degeneration ☐Diabetic Retinopathy ☐Retinal Detachment
☐Glaucoma Other:
Do you use a hand held magnifying glass? ☐Daily ☐Occasionally ☐Never ☐No longer helps
Do you use a tablet (Kindle, I-Pad, etc) to read? ☐No ☐Yes
Do you drive a motor vehicle? ☐No ☐Yes ☐On a regular basis ☐Daytime Only
Difficulty seeing while driving? ☐No
☐Yes ☐Street Signs ☐Traffic Lights
Social History
Do you use tobacco? ☐No ☐Yes
Type of tobacco product used
If YES, for how long have you used tobacco
years
Quit tobacco use in (year quit, ie 1999) Do you consume alcohol? ☐No
☐Yes Type/Frequency
Do you use illegal drugs? ☐No ☐Yes
Are you pregnant or nursing? ☐N/A ☐No ☐Yes
History/exposure to: ☐None ☐HIV/AIDS ☐Hepatitis ☐Gonorrhea
☐Syphilis
☐None
REVIEW OF SYSTEMS - Please check only those that apply:
Eyes: Difficulty recognizing: ☐faces ☐news print
☐distortion ☐loss of side vision ☐itching
☐light sensitivity ☐eye pain ☐stye
☐flashes ☐floaters ☐certified legally blind
Skin: ☐rash
Bones/ Joints/ Muscles: ☐Arthritis
Endocrine: Diabetes ☐No ☐Yes For how long have you been treated for diabetes? years
Head: Headaches ☐No ☐Yes For how long have you had headaches? .years months
Ears/Nose/Throat: ☐Allergies
☐Sinus Infections
Vascular/ Cardiovascular: ☐High Blood Pressure
Nervous System: ☐frequent falls
Do you wear Eye Glasses ☐No
☐Stroke
☐difficulty walking
☐ Yes
For:
☐TIA (mini-stroke)
☐ seizures
☐ Distance
☐Near (Reading)
☐Both
How old are your glasses? years old
Do you have an eyeglass prescription you have not yet filled?
CURRENTLY wearing Contact Lenses? ☐No
☐Bifocal
☐Yes ☐Soft
☐No
☐Yes
☐Hard/Gas Permeable ☐Mono-vision
Brand/Lens
Right Lens Power . Left Lens Power
I REMOVE my contacts: ☐Every Evening
Other
☐Once a Week
☐Once a Month
I REPLACE my contacts
☐Daily
☐Weekly
☐Monthly
☐Quarterly ☐Annually
Other:
Patient’s Signature
ACKNOWLEDGMENT OF RECIPT OF NOTICE OF POLICY PRACTICES
Brian M. Celico, OD
Low Vision Specialist
7150 Greenville Avenue, Suite 305 Dallas TX 75231
Office: 214-265-1111 Fax 214-265-1189
Contact: Brian M. Celico OD
I acknowledge that I was shown and offered a copy of Brian M. Celico, OD Notice of Privacy Practices
on this day
Patient Name:
Sign here:
INSURANCE SIGNATURE ON FILE
I certify that the information given by me in applying for insurance and/or Medicare payment is true and
correct. I authorize my doctor to act as my agent in helping me obtain payment of my insurance and/or
Medicare benefits, and I request that payment of these benefits be made either to me or on my behalf
to Brian M. Celico, OD, PA for any services and materials furnished. I authorize any holder of medical
information about me to release to the Centers for Medicare and Medicaid Services and its agents and
information needed to determine these benefits payable to related services. If I have other health
insurance coverage (as indicated in Item 9 of the HCFA-1500 claim form or electronically submitted
claim), my signature authorizes release of the above medical information to the insurer or agency
shown, and authorizes my doctor to act as my agent, as above.
Sign Here
Date
Low Vision Specialist
7150 Greenville Avenue, Suite 305 Dallas TX 75231
Office: 214-265-1111 Fax 214-265-1189
Contact: Brian M. Celico OD
Authorization for Release of Identifying Health Information
Patient Name
Patient Address
Patient Phone Number
I authorize the professional office of my optometrist named above to release health information
identifying me (including if applicable, information about HIV infection or AIDS, information about
substance abuse treatment, and information about mental health services) under the following Terms
and Conditions.
1.
Detailed description of the information to be released: any information relating to visits to this
office.
2.
To whom may the information be released: family members or others, assisting in
understanding or helping guide patient care
The purpose(s) for the release: at the request of the
individual.
4.
Expiration date or event relating to the individual or purpose for the release: Until further
notice. Or,
It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat
you if you choose not to sign this authorization.
If you sign this authorization, you can revoke it later. The only exception to your right to revoke
is if we have already acted in reliance upon the authorization. If you want to revoke your authorization,
send us a written or electronic note telling us that your authorization is revoked. Send this note to the
office contact person listed at the top of this form.
When your health information is disclosed as provided in this authorization the recipient often
has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the
information as he/she wishes. Sometimes, state/federal law changes this possibility.
For marketing authorization: we will not receive direct or indirect remuneration from a third
party for disclosing your identifiable health information in accordance with this authorization.
I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE
DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBE IN THIS FORM.
Date
Patient Signature
If you are signing as a personal representative of this patient, describe your relationship to the
patient and the source of your authority to sign this form.
Relationship to Patient
Patient Name
Source of authority: at the request of the individual
Brian M. Celico, OD
Low Vision Specialist
7150 Greenville Avenue, Suite 305 Dallas TX 75231
Office: 214-265-1111 Fax 214-265-1189
Pharmacy Name: Phone Number:
Medication List
List ALL medications you are currently taking, including: Prescription medication, over-the-counter
medications, eye medication, and herbal remedies.
List your Eye Medication(s)
List Oral Medication(s) (Pills)
Medication Allergies
List any and ALL medications you are allergic to and the TYPE of reaction you have to each
☐Check if you have no known allergies to medications.
Patient Name:
Patient’s Signature:
Date: