Download MEDICAL HISTORY RECORD Name: _______ Home #: ________

MEDICAL HISTORY RECORD
Name: _______________________________________________ Home #: __________________________Cell#: ________________________
Address: ________________________________________ Apt#:_________ City:___________________ State:______ Zip Code: ___________
Birth Date: _____/______/_______ Age:______ Email: _______________________________________________ Marital Status:____________
SSN:_____-_____-_______ Employer:__________________________ Occupation:_______________________ Work#:____________________
Vision Insurance: _______________________________________________ Primary S.S.N./ID#: ______________________________________
Medical Insurance: ______________________________________________ ID#:___________________________________________________
Personal Medical Information: Which of the following conditions do you experience? Please check all that apply
□
High Blood Pressure
□
Neuropathy
□
Depression
□
Cancer Type _____________________
□
Diabetes Type _______
□
Seasonal Allergies
□
Gastrointestinal Disease
□
Lupus
□
Heart Disease
□
Arthritis
□
Genitourinary Disease
□
Fibromyalgia
□
Asthma
□
Skin Conditions
□
Thyroid
□
Other __________________________
Date of your last routine eye exam: ________________________ Where? ______________________________
Do you have allergic reactions to medications or other substances?
□ Yes
□ No
If yes, please list: ___________________________________________________________________________________________________
Name of Family/Primary Doctor _____________________________________________ Phone/Fax: ________________________________
Please check Yes or No
Do you smoke?
□ Yes
□ No
Do you drink alcohol? □ Yes
□ No
Are you pregnant or nursing? □ Yes
□ No
□ N/a
Please list any current medications: _____________________________________________________________________________________
Do you have any family history of any of the following? If Yes, please check all that apply
□ High Blood Pressure
□ Macular Degeneration
□ Cataracts
□
□
Diabetes
Retinal Detachment
□
□
Other
Glaucoma
Please explain any boxes you have checked ____________________________________________________________________________
Do you have any of the following? If Yes, please check all that apply
□ Dry Eyes
□ Eye Surgeries
□ Cataracts
□ Iritis/Uveitis
□ Eye
Injuries
□ Blurred Vision
□ Lazy Eye
□ Eye
Infection
□ Corneal
Abrasion
□ Diabetic Eye
Disease
□ Macular
Degeneration
□ Glaucoma
□ Wear Glasses
□ Retinal Detachment
□ Wear Contacts
Brand/Type:
Whom may we thank for referring you? ____________________________________________________________________________________
I hereby assign all vision and medical benefits to which I am entitled and any other plans to Dr. Paul Tachau and Associates of Accent on Vision.
I hereby authorize said assignee to release all information necessary to secure the payment. I agree that I am responsible for my bill regardless
of whether my insurance pays or denies my claim. I understand that there are no refunds for examinations/treatment services or material
purchases including eyeglasses, and am aware that vision insurances do not cover medical or surgical treatment of eye injury or disease (allergy,
dry eye, glaucoma, etc.) and that the reason for my visit today will dictate which services will be rendered and which payer will be billed. All copays and balances are due at check out on day of service (deductibles also apply), and balances older than 45 days may be subject to additional
charges and interest. I am also acknowledging that I have reviewed Accent on Vision’s Notice of Privacy Practices.
Patient Signature (or personal representative): _________________________________________________ Date: ______________
Relationship to Patient (if signed by a personal representative of patient): _______________________________________________
Optomap Digital Retinal Imaging
Our doctors are concerned about retinal diseases such as macular degeneration, glaucoma,
retinal detachments, and diabetic retinopathy; all of which can lead to partial loss of vision or
blindness. Additionally, systemic diseases such as diabetes and high blood pressure can be
detected with a retinal examination. Eye exams with retinal evaluations can help you safeguard
both your eyesight and general health.
The Optomap Digital Retinal Imaging allows us to thoroughly evaluate your internal eye health with
dramatically improved precision that includes a depth in the retina not seen with regular dilation. The doctor strongly
recommends that all patients have this procedure performed annually. It is especially important for people who
have:




Headaches
Diabetes
High Blood Pressure
High Cholesterol


Family history of Glaucoma, Macular
degeneration, and/or blindness
Family history of Diabetes and/or
High Blood Pressure
With an annual Optomap, our doctors can track your eye health for concerns, comparison, and treatments.
Because Medical and Vision insurances do not pay for routine photos, there is a $39.00 fee for this procedure. The
Optomap eliminates the need to be dilated with drops, in most cases. (Please advise staff if you have history of epilepsy.)
Visual field testing can assist in early detection of diseases along the optic nerve pathway. Glaucoma and
neurological conditions that cause damage to central and peripheral vision can be detected early in the disease process
with this technology. We are committed to the prevention of eye diseases and want to stress that early detection is the
key to long term health.
______ I ELECT to have an Optomap Digital scan of my retina.
Fee: $39.00+Tax (Not covered by insurance)
______ I ELECT to do the package which consists of both the Optomap retinal scan and Visual Field.
Fee: $49.00+Tax (Not covered by insurance)
______ I DECLINE the Optomap and choose to be dilated today. I understand that my vision will be slightly blurry
and light sensitive for 3-4 hours after dilation.
No fee. Covered by insurance.
______ I DECLINE BOTH the Optomap and dilation. I understand that the potential for partial or total loss of vision
may exist due to undetected eye disease. I therefore release Dr. Tachau and associates from any liability resulting from
failure to diagnose or treat any eye condition due to the lack of diagnostic information, which could have been
obtained by performing these tests.
Signature: __________________________________________________________ Date: _________________