Patient History Form Patient InformationToday's Date MM slash DD slash YYYY Name First Mi Last Date of Birth MM slash DD slash YYYY AgeSex M F Address Street Address City State / Province / Region ZIP / Postal Code Cell PhoneHome PhoneWork PhonePatient's SSNEmployer (or School) Occupation (or Grade) Race Language Spouse (or Parent's Name) Spouse (or Parent's Work) Email Address (For Advantage Eyecare use only)What is the major purpose of your visit? Are there any problems with your current contact lenses or glasses? Yes No please explain. Insurance InformationVision insurance Subscriber Name First Last Subscriber SSNSubscriber Birth Date MM slash DD slash YYYY Primary Medical insurance Subscriber Name First Last Subscriber ID#Subscriber Birth Date MM slash DD slash YYYY Do you participate in a flex spending account? Yes No How will you settle your account today Cash Check Credit Card HIPPA Privacy RuleDue to the HIPPA Privacy Rule, we ask that you would list the following person or persons to receive your Protected Health Information (PHI) pertaining to your medical care other than yourself. any Doctor. or Staff involved in your careName First Last Relationship Name First Last Relationship Name First Last Relationship Lifestyle QuestionsD you...(check box if your answer is yes) ..work at a computer ..think you might benefit from thinner, lighter lenses? ..have interest in a "test drive" of the latest contact lens designs? ..spend time outdoors? How many Hrs/week ..have prescription sun wear ..prefer not to wear glasses at times ..want information on Laser Vision Correction surgery ..have interest in a non-surgical approach to vision correction ..have children? How many? ..have family members in need of eyecare Hobbies Have you ever experienced, been diagnosed, or treated for any of the following? Blurry Vision Burning Cataracts. Corneal Abrasions Crossed Eye/Eye Turn Double Vision Eye Infections Eye Injury Flash of Light Floaters/Spots Glaucoma Grittiness Headachcs lritis/Uveitis Itchiness Lazy Eye Macular Deceneraiion Occasional Retinal Detachment Sunlight Sensitivity Tearing Trouble seeing at Night Uncomfortable Glasses Other Eye Disorders --Advantage Eyecare's Dr.'s and Staff are fully dedicated to excellence, We promise you the highest standard of Eye Care .. providing as lifilime of healthy vision and quality of life. --This we pledge to each one ofour paiients. You are our highest priority. The information in this confidencial Case history form is critical for the evaluation of your vision And health Patient Medical HistoryName of Family Physician First Last Town Date of Last Physical Check-up MM slash DD slash YYYY CURRENT MEDICATIONS (Rx or Over the Coulter) (List name or medications including eye drops, vitamins. & birth control pills) Add RemoveAllergies to medications? Yes No What medications Have you had any surgeries? Yes No Do you use cigarettes/tobaccco? Yes No 1 Pack per day? Yes No Do you consume alcohol? Yes No How much?Have you ever been diagnosed or treated for the following health problems? Diabetes Yes No Hypertension. Yes No Thyroid Yes No Heart Disorders Yes No Cancer Yes No Fatigue Yes No Unusual weight gain/lose Yes No Ear/Nose/Throat (Allergies) Yes No Cholesterol Yes No High Blood Pressure Yes No Bronchitis Yes No Respiratory Yes No Kidney Yes No Genitourinary (urinary/reproductive) Yes No Digestive Yes No Endocrine Yes No Muscle/Bone Yes No Integumentary (Skin) Yes No Eczema/Rashes Yes No Neurological Yes No Psychological Yes No Arthritis Yes No Blood/Lymph Yes No I acknowledge that the above is true to the best of my knowledge and I received a copy of Advantage EyeCare's Notice of Privacy Practices:SignaturePatient/legal GuardianDate MM slash DD slash YYYY Doctor SignatureDate MM slash DD slash YYYY Patient Eye HistoryDate or Last Eye Exam MM slash DD slash YYYY By whom'? Have you ever tried contact lenses ? Yes No Do you currently wear contact lenses? Yes No What kind? Solutions used Are you satisfied with the vision and comfort of your contact lenses? Yes No Would you prefer clear contact lenses or colored contact lenses? Clear Colored If you wear bifocals. do the lines or head tilting bother you? Yes No Family MedicaI Eye History (Cheek all that apply)is there a family medical history of any of the following: (Please check boxes)Blindness Yes No RelationShip(Mother's or Father's side) Cataracts Yes No RelationShip(Mother's or Father's side) Corneal Problems Yes No RelationShip(Mother's or Father's side) Diabetes Yes No RelationShip(Mother's or Father's side) Glaucoma Yes No RelationShip(Mother's or Father's side) Heart Disease Yes No RelationShip(Mother's or Father's side) Lazy Eye Yes No RelationShip(Mother's or Father's side) Macular Degeneration Yes No RelationShip(Mother's or Father's side) Retinal Problems Yes No RelationShip(Mother's or Father's side) Please be advised if you are using insurance coverage for today's visit, this is a contract between you and your insurance company...not Advantage EyeCare There have been many changes with insurance companies. Upon arrival we will need to see your insurance cards and know the name of your vision plan. Vision plan names are often different than your medical plan name if we are not providers for your insurance plan, we will give you the information detailing your charges for the day so that you may send it in for reimbursement. You will be responsible for payment on the day of service
