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____ Medical History Questionnaire______ Name: Today’s Date: Address: Phone: Work Phone: Birth Date___ /___ / ___ SS# Cell Phone: Last Eye Exam___ / ___ / ___ Dilated with last exam? Yes Email: No Location of last exam Who may we thank for referring you? Insurance Holders Name: SS#: ____Birth Date___ /___ / ___ Medical History Name of Medical Doctor Do you have any allergies to medications no yes If yes, explain List any medication you take (include oral contraceptives, aspirin, over the counter medication and home remedies): List any of the following that you have had: lasik, crossed eyes, lazy eye, drooping eyelid, glaucoma, retinal disease, cataracts, eye infection or eye injury: Are you pregnant and/or nursing Do you wear glasses? Do you wear contact lenses? Type of contact lenses: Ridged No No No Soft Yes Yes If yes, how old is your present pair of lenses? Yes If yes, how old is your present pair of lenses? Disposable Brand: Power: Family History Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions; DISEASE/CONDITION NO YES ? RELATIONSHIP TO YOU Cataract Glaucoma Macular Degeneration Retinal Detachment/Disease Cancer Diabetes Heart disease High blood pressures Other Please turn this form over and complete side two Social History Do you drive? No Yes If yes, do you have visual difficulty with glare or halos Do you use tobacco products? Do you drink alcohol? No Yes No Yes No Yes If yes, type / amount / how long: If yes, type / amount / how long: Review of Systems Do you currently, or have you ever had any problems in the following areas: EYES Loss of Vision Blurred Vision Distorted Vision/Halos Loss of Side Vision Double Vision Dryness Mucous Discharge Redness Sandy or Gritty Feeling Itching Foreign Body Sensation Excess Tearing / Watering Glare / Light Sensitivity Eye Pain or Soreness Chronic Infection of Eye Sties or Chalazion Flashes / Floaters in Vision Tired Eyes NO YES ? EARS, NOSE, MOUTH, THROAT Allergies Sinus Congestion Asthma Chronic Bronchitis Emphysema Diabetes High Blood Pressure BONE / JOINT / MUSCLES Rheumatoid Arthritis CONSTITUTIONAL Fever, weight Loss / Gain o GENITOURINARY Kidney / Bladder INTEGUMENTARY (Skin) NEUROLOGICAL Headaches Migraines Seizures Occupation / Work you do? How many hours/day on a computer? What is your hobby (sports/leisure)? Do you wear protective eyewear for sports or work? What are you doing to protect your eyes from ultraviolet exposure? Other information/comments: ? VASCULAR / CARDIOVASCULAR Life-style Questions Do you have sunglasses? YES RESPIRATORY ENDOCRINE Thyroid / Other Glands NO o NOTICE OF PRIVACY PRACTICE ACKNOWLEDGMENT I UNDERSTAND THAT, UNDER HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT OF 1996 (HIPPA), I HAVE CERTAIN RIGHTS TO PRIVACY REGARDING MY PROTECTED HEALTH INFORMATION. I UNDERSTAND THAT THIS INFORMATION CAN AND WILL BE USED TO: CONDUCT, PLAN, AND DIRECT MY TREATMENT AND FOLLOW-UP AMONG THE MULTIPLE HEALTHCARE PROVIDERS WHO MAY BE INVOLVED IN THAT TREATMENT DIRECTLY AND INDIRECTLY. OBTAIN PAYMENT FROM THIRD-PARTY PAYERS. CONDUCT NORMAL HEALTH CARE OPERATIONS SUCH AS QUALITY ASSESSMENTS AND PHYSICIAN CERTIFICATIONS. I HAVE RECEIVED, READ, AND UNDERSTAND YOUR NOTICE OF PRIVACY PRACTICES CONTAINING A MORE COMPLETE DESCRIPTION OF THE USE AND DISCLOSURES OF MY HEALTH INFORMATION. I UNDERSTAND THAT THIS ORGANIZATION HAS THE RIGHT TO CHANGE ITS NOTICE OF PRIVACY PRACTICES FROM TIME TO TIME AND THAT I MAY CONTACT THIS ORGANIZATION AT ANY TIME AT THE ADDRESS ABOVE TO OBTAIN A CURRENT COPY OF THE NOTICE OF PRIVACY PRACTICES. I UNDERSTAND THAT I MAY REQUEST IN WRITING THAT YOU RESTRICT HOW MY PRIVATE INFORMATION IS USED OR DISCLOSED TO CARRY OUT TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS. I ALSO UNDERSTAND YOU ARE NOT REQUIRED TO AGREE TO MY REQUESTED RESTRICTION, BUT IF YOU DO AGREE, THEN YOUR ARE BOUND TO ABIDE BY SUCH RESTRICTIONS. PATIENT NAME: _____________________________________________RELATIONSHIP TO PATIENT: ______________________________________ SIGNATURE: _____________________________________________ ___DATE: _______________________________________ OFFICE USE ONLY I HAVE ATTEMPTED TO OBTAIN THE PATIENT’S SIGNATURE IN ACKNOWLEDGEMENT OF THIS NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT, BUT WAS UNABLE TO DO SO AS DOCUMENTED BELOW: OFFICE PERSONEL: ______________________________________________________DATE:________________________________ REASON: _____________________________________________________________________________________________ NOTICE DUE TO THE CONSTANT CHANGE IN INSURANCE, IT IS NO LONGER AN EASY JOB TO INTERPRET EACH INDIVIDUAL POLICY. PLEASE REMEMBER THAT YOUR INSURANCE POLICY IS BETWEEN YOU AND YOUR INSURANCE COMPANY AND NOT BETWEEN THE INSURANCE COMPANY AND THE DOCTOR. IT IS YOUR RESPONSIBILITY TO KNOW YOUR INDIVIDUAL COVERAGE. PLEASE DON’T GET ANGRY AT US IF YOUR INSURANCE DOES NOT COVER SOME SERVICES. ALL INSURANCE POLICIES HAVE EXCLUSIONS AND MOST POLICIES HAVE DEDUCTIBLES AND COPAYMENTS, WHICH NEED TO BE MET BEFORE COVERAGE IS ALLOWED. NAME (print) _________________________ SIGNATURE__________________________ DATE_______________________________
