Download click here to our new patient forms

Patient Information
Patient’s
Name:
Sex:
Address:
Age:
Date
of Birth:
Mo.
Day
Year
Y
N
Social Security #:
Street
Occupation:
City
State
Zip
Is today’s visit due to an accident?
/
Phone
Numbers:
Home
Work
Cell
Employer
Name:
Work
Address:
Street
City
State
Zip
Emergency Contact Information
Emergency
Contact
Name:
Relationship
to Patient:
Phone
Numbers:
Home
Work
Cell
Financial Guarantor Information
(Who carries the insurance or is responsible for payment of the patient’s bill?)
Guarantor
Name:
Relationship
to Patient:
First
MI
Last
Address:
Date of
Birth:
Social
Security #:
Street
City
State
Zip
Phone
Numbers:
Home
Work
Employer
Name:
Work
Address:
Please complete reverse side ↓
Cell
Glen Ellyn Ophthalmology Associates, Ltd.
Assignment of Benefits, Release of Information,
Receipt of Privacy Policy and Consent to Treatment
Assignment of Benefits:
I request that payment of any authorized insurance and/or Medicare or Medicaid
benefits be made on my behalf to Glen Ellyn Ophthalmology Associates, Ltd.
Release of Information:
I authorize the release of my medical information, including my diagnosis,
records of any examination or treatment, and/or records of charges for services
rendered to other doctors, hospitals or insurance companies concerned in my
care and treatment. This release will be valid until I notify you otherwise in
writing.
Consent to Treatment:
I voluntarily consent to such care and treatment as prescribed by the physician
as is necessary in his or her medical judgment.
Privacy Policy:
I have received a copy of the privacy policy for Glen Ellyn Ophthalmology
Associates, Ltd.
My signature below confirms that I have read the Assignment of Benefits, Release of
Information, Receipt of Privacy Policy and Consent to Treatment and agree with its
terms and conditions. It will remain in effect until revoked by me in writing. I consider
an image of this document scanned into my medical record as valid as an original.
________________________________
Patient’s Signature (or Parent/Guardian)
_____________
Date
GLEN ELLYN OPHTHALMOLOGY ASSOCIATES, LTD.
Robert J. Barnes, MD
Kim A Lindenmuth, MD
Sophia M. Sarkos, MD
Varun K. Malhotra, MD
45 S. Park Boulevard, Suite 375, Glen Ellyn, Illinois 60137
(630) 858-4660 / Fax (630) 858-9511
Name:
Age:
Date:
PATIENT EYE HISTORY:
1. Is there a special problem that brings you in today? If yes, please explain:
2. Have you been told you have glaucoma?
Age at diagnosis: _____
Yes _____
No _____
What was your highest eye pressure? ________
3. Have you been told you have a cataract, macular degeneration, diabetic eye
disease, or other eye disease? Please list:
4. Do you wear glasses for distance? ____
For near? ____
Bifocals? ____
5. Do you currently have any problems in the following areas?
Yes
No
Explain Problem
Loss of Vision
Blurred Vision
Distorted Vision (halos)
Trouble Seeing Road Signs
Glare / Light Sensitivity
Dryness / Burning
Itching / Mucous Discharge
Excessive Tearing
Infection of Eye Lid
Double Vision
6. Please list all eye surgeries:
7. Please list your eye medications:
Medicine:
Date:
Which Eye:
(please continue to the other side)
How Often?
GENERAL MEDICAL HISTORY:
1.
Do you have any allergies to medications?
Yes ___
No ___ (please list):
2.
List current medications (other than eye medications):
3.
List past operations (other than eye operations):
4.
Do you currently have problems in any of the following areas?
Yes
No
(Please circle any that apply)
General:
Cardiovascular:
Lungs:
Gastrointestinal:
Genitourinary:
Skeletal:
Skin / ENT
Neurologic:
Psychiatric:
Endocrine:
Cancer:
Other Problems:
Weight Loss
Fatigue
Loss of Appetite
Heart Disease
High Blood Pressure
Irregular Heartbeat
Heart Attack
Angina
Asthma
Emphysema
Stomach Ulcers
Colitis
Kidney Disease
Kidney Stones
Arthritis: Rheumatoid
Osteoarthritis
Lupus
Skin Cancer
Rosacea
Hearing Loss
Seizures Stroke Migraine Headaches Multiple Sclerosis
Depression
Anxiety
Thyroid Disease
Diabetes
All Blank Responses are Negative: Yes _____ No _____
FAMILY EYE HISTORY:
1.
Does anyone in your family have glaucoma?
Yes _____ No _____
Relationship
2.
Age Diagnosed
Does anyone in your family have cataracts,
macular degeneration, color blindness or other
eye diseases?
Yes _____ No _____
Relationship
3.
Diagnosis
Which other major diseases are present in your family?
SOCIAL HISTORY:
Occupation:
Do you smoke?
Yes _____
Who referred you to our office?
Who is your family physician?
Physician Signature:
Marital Status:
N o _ _ _ _ _ If Yes, how much?
Date: