WELCOME TO COPPELL VISION CENTER 541 E. Sandy Lake Road, Coppell, Texas (972) Personal Information
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1 WELCOME TO COPPELL VISION CENTER 541 E. Sandy Lake Road, Coppell, Texas (972) (Please Print Clearly) Personal Information Last Name: First Name: Exam Date: / / Street Address: City/State/Zip: Preferred Phone #: Alternate Phone #: SS #: - - Birthdate: / / Age: Male Female Marital Status: [ ] Married [ ] Single [ ] Widowed Employer: Occupation: What is the main reason for your visit? How did you hear about our office? Insurance Information Relationship to Insured: [ ] Self [ ] Spouse [ ] Child HEALTH Insurance: VISION Insurance: Insured s ID #: Insured s ID #: Group ID #: Group ID #: Insured s Information if not Self: Last Name: Street Address: Social Security #: - - First Name: City/State/Zip: Birthdate: / /
2 Medical History Questionnaire Name: Date: Birth Date: / / Last Medical Exam: / / Last Eye Exam: / / Name of Medical Doctor(s): Patient Medical History Are you allergic to any medications? If yes, please list: Please list any past or current medical conditions/ diagnoses: Please list your current medications: Please list any major injuries, surgeries, and/or hospitalizations (particularly eye related): Do you wear glasses? If yes, how old are they? Do you wear contacts? If no, are you interested in trying them? If yes, what brand/powers (if known): Are you satisfied with the comfort and wearing time of your current contacts? Are you interested in trying a new brand or type of contact lens? Are you interested in refractive surgery (i.e. LASIK)? Patient Social History What are your hobbies/ extracurricular activities? Do you use tobacco? If yes, type/amount/how long: Do you drink alcohol? If yes, type/amount/how long: Do you use recreational drugs? If yes, type, amount/ how long: Family History Do you or any of your immediate family members (living or deceased) have any of the following conditions? Condition No Yes Unsure Relationship to Patient Glaucoma [ ] [ ] [ ] Macular Degeneration [ ] [ ] [ ] Cataracts [ ] [ ] [ ] Retinal Detachment [ ] [ ] [ ] Flashes and/or Floaters [ ] [ ] [ ] Amblyopia (Lazy Eye) [ ] [ ] [ ] Eye turn [ ] [ ] [ ] Diabetes [ ] [ ] [ ] Severe Headaches [ ] [ ] [ ] Other [ ] [ ] [ ]
3 PATIENT REVIEW OF SYSTEMS Do you have a current or past history of medical problems in the following areas? System Yes No If Yes, please give a brief explanation: Eyes/Vision [ ] [ ] Integumentary (Skin) [ ] [ ] Ears, Nose, Mouth, Throat [ ] [ ] Respiratory (Lungs, Breathing) [ ] [ ] Cardiovascular (Heart, Blood Pressure, etc.) [ ] [ ] Musculoskeletal (Muscles, Bones) [ ] [ ] Gastrointestinal (Stomach, Intestines) [ ] [ ] Genitourinary (Genitals, Kidney, Bladder) [ ] [ ] Neurological (MS, Seizures, etc.) [ ] [ ] Endocrine (Thyroid, Diabetes, etc.) [ ] [ ] Psychiatric (Depression, Anxiety, etc.) [ ] [ ] Hematologic (Anemia, Bruising, etc.) [ ] [ ] Allergic/Immunologic (allergies, lupus, etc.) [ ] [ ] Sleep Apnea [ ] [ ] Other (Cancer, etc.) [ ] [ ] General Health Status: [ ] Excellent [ ] Good [ ] Fair [ ] Poor OFFICE USE ONLY Doctor s Signature Review Date
4 ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES The law requires that the staff at Coppell Vision Center make every effort to inform you of your rights related to your personal health information. I have read (or given the opportunity to read) Coppell Vision Center s Notice of Privacy Practices and agree to continue my care with Coppell Vision Center under said terms. List below the name of the person(s) to whom we may give information regarding your condition, treatment, diagnosis, or financial responsibility. Spouse: Son/Daughter: Parent: Other: Initial here if you wish that your information not be disclosed to anyone List any specific person who should not have this information: List the number(s) where we may reach you and circle the primary: May we leave a detailed voic message on these numbers? Knowing that standard communication may not be totally secure, I still consent, if requested, to communications from my doctor or staff through my standard . I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I hereby authorize Coppell Vision Center to release all information required to determine benefits and process any insurance claims to secure payment. I also authorize my insurance benefits be paid directly to the doctor, and I understand I am financially responsible for all unpaid charges not covered by my insurance. If needed, I authorize the use of this signature on all insurance claim submissions. Patient Date If you are signing as a personal representative of the patient, please indicate your relationship Representative Relationship to Patient
5 At Coppell Vision Center we pride ourselves on providing our patients with the best possible standard of care. Because of this we perform the new Daytona Optomap Retinal Exam with our patients. This non-invasive procedure allows your doctor to see a much broader and more detailed view of the retina than is possible with conventional methods. When reviewed, the scan becomes a permanent part of your medical file, enabling your doctor to make important comparisons should potential vision threatening conditions show themselves at a future examination. Dr. Pels and Dr. Elston strongly believe that the Optomap Retinal Exam is an essential part of your comprehensive eye exam and prescribes it for all patients once per year. This scanning technology allows us to view the inside of your eye without the use of dilation drops. We may be able to detect early signs of glaucoma, diabetic retinopathy, retinal detachments, macular degeneration, hypertension, and many other serious vision and health concerns. Takes less than one second to take picture of up to 80% of your retina Digital record of the internal structure of your eye to compare at future visits No blurring or light sensitivity following exam You can see the inside of your own eye A dilated exam can be performed at your exam, but please note that it may have an effect on your vision for 3-4 hours (blur and light sensitivity). Although the dilation is a very thorough way to look at the retina, there is no permanent record without photo documentation. The doctor cannot fully assess the health of your eyes without the Optomap or a dilated exam, either one or the other is recommended. Depending on the circumstances we may need to do both. There is an additional charge of $39 per patient for this service. Please note the Optomap is NOT always covered by insurance plans, therefore you may be charged at the time of service. Please take the Optomap photos of my eyes today ($39 additional charge) I decline the photos today and request a dilated exam (no additional charges). I decline both photos and dilation of my eyes today. I understand and am aware that the doctors may not be able to thoroughly examine the back of the eye. Patient s Signature (or Guardian) Date
Welcome. Medical History Do you have any allergies to medications? No Yes If Yes, Please Explain
Welcome Name: Address: City: State: Zip: Employer: Occupation: Birthdate: / / Social Security #: - - Name of Primary Care Physician: Guardian (If Applicable): Today s Date: / / Cell Phone: - - Home Phone:
Immediate Family History Please list Father, Mother, Brother, Sister or Children
: Social Security # Name: of Birth: Age: Address: City: State: Zip: Home#: Cell#: Work#: E-mail: Status: Married Single Divorced Widowed Work Place/School: Occupation/Grade: Emergency Contact (Name/Phone):
Shallotte Vision Care J. Mark Saunders, OD PA 4637 Main Street Shallotte NC Patient Demographic Information
Shallotte Vision Care J. Mark Saunders, OD PA 4637 Main Street Shallotte NC 28470 Patient Demographic Information Account # Last Name: SSN: / / First: Middle: Marital Status: Single Married Separated Nickname:
Preferred Name: First Name: Last Name: Middle Initial: Mailing Address: City: State: Zip: Alternate number: address:
Welcome to our office! We want to provide you with the very best in vision care. In order for us to serve you better, we need certain biographical information from you. Please complete the following data
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM B S M R W A G KS MAC Z GR SO ZA L Please tell us about yourself so we can help you make the best decisions about your care. Date: Social Security #: E-mail: Name: MR / MRS / MS
Retinal Consultants of San Antonio PATIENT REGISTRATION
PATIENT REGISTRATION Today s Date Referred by Patient Full Name Home Address City State Zip Code Home Phone Cell Phone E-mail address Date of Birth Preferred Method of Contact: Home Phone / Cell Phone
MEDICAL HISTORY QUESTIONNAIRE
MEDICAL HISTORY QUESTIONNAIRE Name Birth Date Name of doctor referring you Doctor Phone Doctor Address Date of last eye exam REVIEW OF SYSTEMS Do you currently have any problems in the following areas?
Hospital he hospital is located near the interchange of highway 217 and (US 26).
Welcome to our Clinic! Our goal is to provide you with the highest quality medical care available. Please bring the completed enclosed paperwork along with your insurance card and legal picture ID to your
Social Security Number: Date of Birth: May we contact you at work? Yes No PLEASE PROVIDE INSURANCE CARDS FOR COPIES
UPDATES PATIENT DEMOGRAPHICS Date: Single Married Widowed Divorced Name: Male Female Address: Street Apt. # City State Zip Email Address: Social Security Number: Phone: Home: Cell: Occupation: Emergency
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE Name: Today s Date: First Middle Last Gender: Male Female Date of birth: Age: Home Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) Occupation: SSN: Employer: Time of employment
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
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Setting Your Sight Back on Life.
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Medical History Form. Patient Information. Medical History. Middle Initial: Date: Salutation: Sex: First Name: Last Name: Current Address:
Medical History Form Patient Information Salutation: Sex: Current Address: Email: Employer: First Name: Last Name: Middle Initial: Date: City: Zip Code: Phone 1: Phone 2: Date of Birth: Referral Source:
George M. Salib, M.D., Inc.
George M. Salib, M.D., Inc. Patient Acknowledgement Regarding Precautions Following Dilation It may be necessary to dilate your eyes during your eye examination or treatment. Dilation results in light
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
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- YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES )
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EYE ASSOCIATES OF MONMOUTH, LLC
EYE ASSOCIATES OF MONMOUTH, LLC In order for us to obtain a complete medical history, it is important for you to fill out this form as completely as possible. This is very important information. Please
Medical History Record
Medical History Record Today s For faster service, please complete the following form prior to arriving at our office. FIRST NAME: M.I. LAST NAME: Address City State Zip Code D.O.B. Sex: M F Email Home
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
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PATIENT DEMOGRAPHICS PATIENT INFORMATION Patient: First Name Middle Initial Last Name Date of Birth SSN Gender: Male Female Address Email City State Zip Code Home Phone ( ) Cell Phone ( ) Occupation Employer
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
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medical questionnaire Date: Day Month Year
medical questionnaire Date: Please answer these questions as completely as you can. We realize that this form is long, but the information in this form will be extremely valuable to us in providing you
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New Patient Information. Which Physician will you be seeing today? How did you hear about our practice?
New Patient Information Which Physician will you be seeing today? How did you hear about our practice? Local Pharmacy Name: Pharmacy Phone #: Pharmacy Location/Address: Name Preferred Age: (Last) (First)
Adult Demographics Form
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PATIENT INFORMATION date: Last Name First Name MI Address City State Zip Cell Phone _( ) Home Phone _( ) Email May we contact you by email? Yes No Date of Birth Age Marital Status Patient s Occupation
Please arrive fifteen minutes early so that we may prepare your medical information for your visit. Allow about one and a half hours for your visit.
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NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE
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Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:
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PATIENT HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician
Thank you very much for choosing us and we look forward to your visit!
Elizabeth Crandall, MD Ophthalmology 136 W. Cherry St Jesup, GA 31545 Phone: (912) 559-2467 Fax: (912) 559-2473 www.crandalleye.com Dear, Thank you for choosing us to provide you with your eye care needs.
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Cheralyn Perkins, DPM David Scalzo, DPM Kathleen Hope, DPM Nicole Branning, DPM TODAY S DATE: / / LEGAL NAME: LAST FIRST MIDDLE
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MEDICAL HISTORY QUESTIONNAIRE Please print and complete this questionnaire prior to your first physical therapy appointment. The purpose of this questionnaire is to help us understand your health status.
NEUROLOGY & SLEEP CLINIC PLC.
` NEUROLOGY & SLEEP CLINIC PLC. Office Use Only New Patient EMG/NCV Disability Exam Dictation Done : TREATMENT OF: Dementia Epilepsy Headaches Medical Retina Multiple Sclerosis Neurology Neuro-Ophthalmology
WELCOME TO FALLS CHIROPRACTIC AND INJURY!
WELCOME TO FALLS CHIROPRACTIC AND INJURY! PATIENT INFORMATION (Most of the information below is required for insurance purposes) DATE: / / FIRST NAME: M.I.: LAST NAME: DATE OF BIRTH: / / CALLED NAME /
Modesto Gastroenterology Medical Corporation
Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298
WELCOME TO OUR OFFICE
PODIATRY / Dr. John Savidakis Jr. (727) 796-1490 WOUND CARE 2701 Park Drive, Suite #6 Fax: (727) 797-5611 Clearwater, FL 33763 WELCOME TO OUR OFFICE Today s Date : / / (Please use black ink.) PATIENT INFORMATION:
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES Medical Complex Drive, Suite 6 Tomball, TX
TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES 13414 Medical Complex Drive, Suite 6 Tomball, TX 77375 281-516-0212 Welcome! We are glad that you have chosen Tomball Regional Internal Medicine Associates
Lake Psychological Services, LLC
Lake Psychological Services, LLC Welcome to Lake Psychological Services and thanks for choosing our office for your health care needs. Seeking treatment is not an easy decision and you may have questions
UnityPoint Clinic - Cardiology
UnityPoint Clinic - Cardiology Date Completed: Appointment Date: Name: Age: Birthdate: / / FIRST MIDDLE INITIAL LAST Referred by: Family Dr.: Reason for visit: Describe briefly, include date of onset:
WELCOME Patient Registration Date:
Patient Information WELCOME Patient Registration Date: Mr. Mrs. Ms. Dr. Name: Last First MI Address: Street Apt. # City State Zip Code Home Tel #: Work #: Cell #: Sex: Female Male Birth Date: Married Single
RED-ROSE CHIROPRACTIC CLINIC, P.S NE 85 TH STREET KIRKLAND, WA (425) fax (425)
PATIENT INFORMATION DATE: BP: P: Patient Name: (First) (Last) (M.I.) Address: City, State: Zip Code: Home #: ( ) Cell #: ( ) Work #: ( ) Date of Birth: Age: Sex: M / F Email: Automatic Appointment Reminder
PATIENT INTAKE AND HISTORY FORM
PATIENT INTAKE AND HISTORY FORM (Please print) Name Date of Birth Race: American Indian or Native Alaskan Asian Black/African-American Native Hawaiian or Other Pacific Islander White Refused to report/unreported
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: Spouse/Partner Name:
Practice: Today s Date: Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E-mail newsletters, reminders, statements, etc. Address: City: State:
The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
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Our office is located at 2030 Drew Street, Clearwater FL, We are on Drew Street, in between N.E Old Coachman Road and Hercules Avenue.
Dear New Patient, Thank you for choosing Dennis M. Lox, M.D to participate in your healthcare. We realize that you could have chosen any other office, so we are honored that you have chosen us. While Dr.
Medical History Form
Medical History Form Name: ; Birth date: / / ; Date: / / Person filling out form: ; Relationship: Thank you for taking the time to fill out this valuable information. This allows us to provide the best