Download Eger Eye Group, PC - The Eger Eye Group

Eger Eye Group, P.C.
Last Name: _________________ Middle Initial: ___ First Name: ______________________ Birth Date: ______________
Street Address: _____________________________________ City/State/Zip: ___________________________________
Home Phone: (____)____________ Work Phone: (____)____________ Email: ___________________________________
Occupation: ____________________ Employer: _______________________________
Soc. Sec. #: __________________
Age: ___ Sex: M F Race: ____________ Accompanied By: _______________________ Relationship: ________________
In case of emergency please contact: ______________________________________ Phone: (____)__________________
Height: ___________ Weight: __________ Primary Care Physician:_ ___________________________________________
Last Eye Exam: _________ Last PCP Visit: ____________
Reason for last visit to PCP (circle one): Wellness Disease Other
Reason for Today’s Visit(Circle): Blurry Vision Itching Redness Glare Mattering Headaches Other: ___________________
REVIEW OF SYSTEMS (please circle all pertinent)
Constitutional: None Fatigue Lightheaded Weakness Muscle Cramps Weight Loss/Gain Loss of Sensation
Cardiovascular: None High Blood Pressure Heart Disease High Cholesterol Angina Carotid Artery Disease
Ear/Nose/Throat/Mouth: None Sinusitis Ringing in Ears Dizziness Vertigo Chronic Strep Dermatitis TMJ
Respiratory: None Asthma COPD Pulmonary Embolism Sleep Apnea Wheezing Sarcoidosis Pneumonia
Gastrointestinal: None Celiac Constipation Crohn’s Disease Acid Reflux Irritable Bowel Ulcers Cancer
Genitourinary: None Prostatic Hyperplasia Bladder Infection Dialysis Incontinence Menopause Endometriosis
Musculoskeletal: None Arthritis Gout Back Pain MS Cramping Lupus Tendonitis Joint Pain Fibromyalgia
Integumentary: None Acne Alopecia Skin Color Changes Rosacea Skin Cancer Vitiligo Easy Bruising Lice
Neurological: None Alzheimer’s Bell’s Palsy Dementia Headaches Migraines MS Parkinson’s Stroke Vertigo
Psychiatric: None ADD ADHD Depression Anxiety Confusion Panic Attacks Schizophrenia Bipolar
Endocrine: None Diabetes (Insulin Non-insulin) High Cholesterol Thyroid (Hyper Hypo) Osteoporosis
Hematologic/Lymphatic: None Anemia Leukemia Lymphoma (Hodgkin’s Non Hodgkin’s) Sickle Cell Lupus
Allergic/Immunologic: None Seasonal Autoimmune Disease Drug Allergies Food Allergies
Other (please explain): _____________________________________________________________________________
Diabetics Only: Last Fasting Blood Sugar: _________ Last HbA1C: _________ Next PCP Visit: ______________________
PAST PERSONAL HISTORY
Please list all surgeries and the date of surgery:___________________________________________________________
________________________________________________________________________________________________
Please list all medications you take including dosage (you may provide a list): ___________________________________
_________________________________________________________________________________________________
Allergies (drug and environmental):
_____________________________________________________________________
Do you have (circle): Glaucoma Cataracts Macular Degeneration Eye Injury Retinal Disease Other Disease
BlindnessEye Turn Lazy Eye Diabetes Dry Eye Blurred Vision Glasses Headaches Flashes Floaters Double
Vision Redness Itching Burning Tearing Tired Eyes Eyelid Droop
Do you wear glasses? Y N Bifocal? Y N Do you wear contact lenses? Y N What kind? __________________________
FAMILY HISTORY (please circle all that apply and list who next to it):
Glaucoma: ____________ Cataracts:_____________ Macular Degeneration: Wet______________ Dry ______________
Eye Injury: ______________ Retinal Disease: __________ Other Disease: __________________Diabetes:
____________
Blindness (include reason): ________________________ Strabismus: ______________ Amblyopia:
_________________
Cancer (include type): _______________ Heart Disease: _______________ High Cholesterol:_______________
High Blood Pressure: ____________ Stroke: _____________ Other (please explain): ____________________________
SOCIAL HISTORY (please circle all that apply):
Have you ever used tobacco? Y N If yes: How long? _______________ Type of tobacco used: _____________________
How many packs per day? ________ Quit when? _________________________
Do you use narcotics? Y N If yes: What type? _____________________________ Frequency of use:
_______________
Do you drink alcohol? Y N If yes: Social only –OR-- ___ drinks per week
Do you drink caffeine? Y N If yes: ____ cups per day
The Eger Eye Group PC requests permission to contact you via mobile phone and/or email for appointment
confirmation and promotional opportunities. Please provide your information below to authorize consent.
Mobile phone____________________ Primary email address ______________________________________________
Patient or Parental Signature: __________________________________ Date: ____________
Re-attestation: Date: __________ Date: __________ Date: _____________ Date: __________
Reviewed by Doctor’s Signature: _______________________________ Date: ___________
Authorizations
Important, please read the following as there has been a significant change made by most insurance companies EFFECTIVE: January 1, 2012
We often have patients that have both vision and medical insurance. They are very different in terms
of the services they cover and it’s important for our patients to understand those differences. Vision coverage
is mainly designed to determine a prescription for eyeglasses (called a refraction), and to evaluate the health
of their eyes. It is not designed or equipped to deal with medical conditions, diagnoses, and/or treatment
plans.
When a medical diagnosis or condition is present (such as high blood pressure, diabetes, or an eye
disease such as infections, dry eyes, allergy, cataracts, macular degeneration, to name just a few) it is necessary to file the claim for your visit with your major medical carrier and the co-pays for that insurance will
apply as well as any non-covered service (like a refraction). Vision insurance does not cover medical eye
problems, just as medical insurance does not cover routine vision problems. Our office does not make these
rules; they are defined by the insurance carriers themselves.
There may be no way to know prior to the examination (especially if you are new to our
office) which type of insurance will apply or with whom our office will be able to file a claim on your behalf.
We make every effort to be a provider for most major carriers for your convenience and we will file those
claims for you when there is a medical problem. In the event that we do not take your major medical/vision
insurance, we will provide you with an itemized receipt so that you may file with your carrier for reimbursement.
If you have any questions, or would like a copy of this authorization statement, please let us know.
I understand the paragraph above and authorize The Eger Eye Group to file a claim with my insurance.
_________________________ _________________________ _______________
Printed Name
Signature
Date
Federal law, Medicare and most health insurances mandate that the following information be
accurately completed. Please answer all appropriate questions.
Commercial Insurance and Medicare Authorization
Name of Insurance Holder:____________________________
Please present your insurance card(s) so a copy may be placed in your record.
Vision Plan:________________________ ID#_____________
“I request that payment of authorized commercial insurance and/or Medicare benefits be made on my behalf
to the doctors of the Eger Eye Group for any services provided me by that physician. I authorize the release
of any medical information about me to the insurance carrier or the Centers for Medicare and Medicaid
Services and its agency to determine these benefits or the benefits payable for related services. I understand
that I am financially responsible to said physician for any balance not covered by my insurance carrier at the
time of service. I understand that any delinquent payments as determined by this office are subject to
collection and civil prosecution by magisterial decree.”
Patient Signature:___________________________________ Date:_____________
Welcome! You are here because you care about your vision and we're here because we
care too! Please fill out this brief questionnaire so that we can better help you to protect
that vision as well as care for the overall health of your eyes.
Name
Date
Please circle how often you currently wear the following forms of sight correction and/or
sight protection…
Contact Lenses
Eyeglasses
Plano Sunglasses
Always
Always
Often
Often
Rarely
Rarely
Never
Never
Always
Often
Rarely
Never
Prescription Sunglasses
Always
Often
Rarely
Never
(Non-prescription)
Your eyewear is a part of your life! It should function perfectly, look great and always feel completely
comfortable! Do you have any of the following problems with your current eyewear?
Please check all that apply.
Too heavy (They leave marks on nose or cheeks.)
Poor fit (They slip down or are uneven.)
Squeeze too hard on the temples
Wrong size (too large or too small)
Difficulty with bifocal
Too much glare
Irritating under fluorescent lights
Inadequate amount of reading area in the lenses
Need constant adjustment
Outdated, faded or worn out
Screws fall out too easily
Other, please comment:
Please tell us what you do! Just circle your participation level in the following activities and indicate
whether or not you currently have eyewear specific for that activity.
I have eyewear
for this activity
At Home / Work:
Reading
Frequently
Infrequently
Never
|
Yes
No
Computer
Frequently
Infrequently
Never
|
Yes
No
Television
Frequently
Infrequently
Never
|
Yes
No
Infrequently
Never
|
Yes
No
Other (musical instruments, hobbies, etc.):
____________
Frequently
Outside:
|
Driving
Frequently
Infrequently
Never
|
Yes
No
Cycling
Frequently
Infrequently
Never
|
Yes
No
Walking/Jogging
Frequently
Infrequently
Never
|
Yes
No
Golf
Frequently
Infrequently
Never
|
Yes
No
Tennis
Frequently
Infrequently
Never
|
Yes
No
Water Sports
Frequently
Infrequently
Never
|
Yes
No
Snow Sports
Frequently
Infrequently
Never
|
Yes
No
Yes
No
Other:
____________
|
Frequently
Infrequently
Never
Do you have any other special visual needs? If so, please describe:
|