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WELCOME TO OUR OFFICE! DATE ______________ Last Name _____________________________ First Name __________________________________ M.I. _____ Age _____ Sex _____ Address ________________________________________ Apt. _____ City ______________________ State ________ Zip _________ SS# __________________ Cell # _________________ E-mail _________________Want to receive Dr. Peneiras’ e-mail newsletters Yes / No Work # _________________ Home # _________________ If student, grade______ School ______________ Occupation _____________ Employer __________________ Employer Address _____________________ Marital Status _______ D.O.B. _____________________ Spousal Information: Name _____________________________ SS# __________________ Occupation ____________________ Work # _______________________ Employer ______________________ Employer Address __________________________ Parental Consent: I hereby authorize the eye physician to treat my minor child __________________________ (parent/guardian signature) Insurance Information: Do you have medical eye insurance? Yes / No Insurance Name __________________________________________ Do you have vision insurance? Yes / No Insurance Name __________________________________________ Do you have insurance for eyeglasses or contact lenses? Yes / No Insurance Name __________________________________________ PLEASE BE ADVISED!!! IF YOU HAVE VISION COVERAGE AND DO NOT TELL US AT THE TIME OF YOUR APPOINTMENT, WE WILL PROVIDE YOU WITH A RECEIPT WHICH YOU CAN SUBMIT TO YOUR INSURANCE. X ___________________________________________________________ (sign here) Insurance Company _____________________ Policy Number _______________________ Subscriber Relationship to Patient ___________ Driver’s License # __________________________________ State Issued ______________________ Do you drive? ________________ Family Physician ________________________ Phone # ________________ Address _____________________ City _______________ How did you learn about our office? (doctor,patient, insur. yellow pages, newspaper, family) Other ________________ Last Eye Exam __________ By Doctor ___________________ Where you purchased your last pair of glasses ______________ Is this your first eye exam? Yes / No Are you pregnant? Yes / No / N/A Have you ever had eye surgery? Yes / No Have you ever had vision therapy, vision training, patching, or orthoptics? Yes / No Do you have any neck/back pains? Yes / No Do you have any dental pains? Yes / No Do you wear: __ Glasses __ Contacts Eye Problems: __ blurred vision at near __ itching __ tearing/watering __ headaches __ eye pain/sore __ squinting __ see spots/floaters __ double vision __ trouble reading signs __ eye trauma __ mucous discharge __ hold book or paper too close __ Bifocal Contacts __ Colored Contacts __ Sunglasses __ Polarized Lenses __ blurred vision at distance __ blurred vision at computer __ burning __ glare from lights __ redness/bloodshot __ eye strain __ poor night vision __ light sensitive __ fatigue during near visual tasks __ tilt head __ see flashing lights __ eye turns in, out, up, or down __ loss of vision __ fluctuating vision __ trouble identifying colors __ drooping eyelids __ poor depth perception __________________________________________________________ other Medications: Include Name/dosage (mg)/how many times daily _________________________________________________________ Allergies to medications ____________________________________ Eye Medications _______________________________ Please circle in the table any condition you or a blood relative have and indicate on the line who has the condition: Glaucoma _____________ Cataracts _______________ Diabetes _______________ High Cholesterol _________ Blindness _____________ Dry Eyes _______________ High Blood Pressure _______ Stroke ________________ Macular Degeneration _____ Amblyopia (lazy eye) _______ Heart Problems __________ Thyroid Problems ________ Retinal Detachment ______ Strabismus (eye turn) ______ Lung Problems ___________ Asthma _______________ REVIEW OF SYSTEMS: (Circle or List problems YOU have in any area) CHECK HERE IF NONE: ______ CONSTITUTIONAL & INTEGUMENTARY: FEVER, WEIGHT LOSS, RASH, SKIN DISEASE, ___________________ HEAD/NECK: SINUS PROBLEMS, POST-NASAL DRIP, RUNNY NOSE, DRY MOUTH, HEARING LOSS, ____________ RESPIRATORY: COUGH, BRONCHITIS, SORTNESS OF BREATH, ASTHMA, EMPHYSEMA, COPD, ______________ CARDIOVASCULAR: CHEST PAIN, CONGESTIVE HEART FAILURE, IRREGULAR RHYTHM, __________________ GASTROINTESTINAL: VOMITING, ULCERS, DIARRHEA, BLOODY STOOLS, _____________________________ GENITOURINARY: GENITAL ULCERS, DISCHARGE, KIDNEY STONES, BLOOD IN URINE, ___________________ ALLERGIC/IMMUNOLOGIC & BLOOD/LYMPHATICS: SEASONAL ALLERGIES, HAY FEVER, _______________ NEUROLOGIC, PSYCHIATRIC & MUSCULOSKELETAL: HEADACHE, MIGRAINES, PARALYSIS, JOINT ACHES, __ SHx: Smoke (cigarettes, cigars, pipe) ______ # per day / Recreational drugs Yes / No / Alcohol (beer, wine, liquor) ____ socially ____ daily I understand and agree that (regardless of my insurance status), I am ultimately responsible for the balance of my account for any professional services rendered. I authorize to release any information and records to any insurance company, adjusty, attorney, or insurance commissioner. I authorize and request payment of medical benefits, including Medicare benefits, be made on my behalf to the practice for professional services and treatment rendered. Lifetime Signature on File ______________________________________________ Date _________________________
