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