- YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES )
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- Hollie Black
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1 NAME (Please Print) First Name M.I. Last Name DATE of BIRTH / / - YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES ) Exam Date:,20 PRESCRIPTIONS DRUGS Please Print MEDICATIONS NAMES ONLY NO PRESCRIPTION ME DICATIONS TAKEN Dosages and Frequency ARE Necessary PRESCRIPTION EYE DROPS 4. Dosages and Frequency ARE Necessary VITAMINS, SUPPLEMENTS and OVER-THE-COUNTER MEDICATIONS NONE TAKEN ALLERGIES to DRUG ALLERGIES EYE DROP ALLERGIES OTHER ALLERGIES NONE KNOWN Do You or Did You Have Please the BOX or Print Diabetes? Multiple Sclerosis? High Blood Pressure? Stroke or Mini-Stroke? Heart Disease? COPD Emphysema, Asthma, Bronchitis? Cancer? Other?
2 YOUR PRIMARY CARE DOCTOR With Contact Information? Dr. Would You Like a Report Sent to Another Doctor? ( Include City ) Dr. REVIEW of SYMPTOMS I am in GOOD HEALTH I (Cardiac) Chest Pain or Discomfort? Irregular Heart Beat? II (Pulmonary) Shortness of Breath? Wheezing (Asthma)? Chronic Cough? Please the BOX if It Applies III (CNS) Headache or Migraines? Seizures or Tremors? DOCTOR S NOTES Memory Problems? Muscle Weakness, Paralysis? IV (Musculo-Skeletal) Arm or Leg Joint Pain? Neck or Back Pain? Do Not Write Here V (Endocrine) Weight Gain or Loss? Heat or Cold Intolerance? Excessive Thirst, Urination? VI (Integumentary) Rashes, Blisters? Dry, Scaly Skin (Eczema)? Rosacea (Acne Rosacea)? VII (Hematologic) Bleeding and Bruising? Frequent Colds, Infections? VIII (GI) Diarrhea? Heartburn, Reflux Disease? IX (GU) Pain, Burning on Urination? myfed25@msn.commyfed25@msn.com
3 EYE HISTORY Do YOU Have or Been Treated For OTHER Please Print Please the BOX if It Applies Glaucoma Crossed or Wall Eyes Cataract Lazy Eye, Amblyopia Macular Degeneration Iritis Keratoconus Retinal Detachment EYE SURGERY OTHER INJURIES Did YOU Have Surgery ( for ) Glaucoma? Retinal Detachment? Cataract? Laser for Diabetes? LASIK or R.K.? Other Eye Laser? Eyes? Concussion? Facial Fractures? Broken Nose? CORRECTIVE LENSES Do YOU Wear Glasses? Gas Permeable Lenses? Contact Lenses? Monovision Contacts? FAMILY EYE HISTORY ( Blood Relatives Only ) Glaucoma Crossed or Wall Eyes Cataract Night Blindness Macular Degeneration Color Blindness Lazy Eye or Amblyopia Blindness YOUR FAMILY HEALTH Diabetes High Blood Pressure DOCTOR S NOTES Do Not Write Here
4 ADDITIONAL MEDICAL HISTORY Do You Have or Been Treated For OTHER : Please Print Please the BOX if It Applies Rheumatoid Arthritis? Lupus? Parkinson s Syndrome? Depression? Thyroid Disease? Kidney Stones? Poor Circulation? H.I.V. or AIDS? CANCER (Type?): Chemotherapy? Radiation Therapy? Cancer Surgery? MAJOR SURGERY ( Other Than Eye Surgery ) HEART (e.g. Stent, Valve Repair, Bypass, Pacemaker) BREAST ORTHOPAEDIC (e.g. Hip, Knee, Shoulder, Spine) COLON GYNECOLOGIC (e.g. Hysterectomy) BRAIN UROLOGIC (e.g. Prostate) CAROTIDS OTHER: SOCIAL HISTORY Do You Currently Use Tobacco? Have You Ever Used Tobacco? Drink Alcohol? Drive a Car? Live Independently? Live Alone? HOBBIES (Music, knitting, sports etc.) DOCTOR S NOTES Do Not Write Here OCCUPATION: ADDRESS: 1 - THANK YOU -
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6 Excellence in EyeCare, Inc. Acknowledgement of Receipt of Notice of Privacy Practices Excellence in EyeCare, Inc. respects your privacy and only uses or discloses your medical information when necessary or appropriate. Our Notice of Privacy Practices describes potential uses and disclosures of your health information by our practice and outlines your medical privacy rights. Please print your name and sign below indicating you have received our Notice of Privacy Practices. Guarantors are required to sign on behalf of minors. Patient s Name: (please print) Signature: Date: Please indicate below your preference about our use and disclosure of your health information. Excellence in EyeCare, inc. will release health information to all guarantors of minors and primary care physicians. I,, authorize the person(s) listed below to discuss my care with or receive my health information provided by Excellence in EyeCare, Inc. (For example, spouse/family memebrs) Name Relationship Phone Number Name Relationship Phone Number Name Relationship Phone Number I,, do not authorize Excellence in EyeCare, Inc. to disclose my health information to any other person except me as the patient. 3
7 Excellence in EyeCare, Inc. Signature on File Assignment of Benefits Financial Agreement I hereby certify that the insurance information provided by me is correct and that Excellence in EyeCare, Inc. will file my claim to the insurance company that I provide to the practice. Initial I request that payment of authorized insurance benefits be made on my behalf to Excellence in EyeCare, Inc. for services provided. I understand that Excellence in EyeCare, Inc. may release information necessary to process my claim. I understand that I am financially responsible for services that are not covered by my insurance plan. I agree that in return for the services provided, I will pay my account at the time service is rendered or will make arrangements satisfactory to the practice. If my insurance company applies a co-payment or deductible to my visit(s), I agree to promptly pay them to Excellence in EyeCare, Inc. However, I understand that I am primarily responsible for the full payment of my bill. Initial I am aware of Excellence in EyeCare s cancellation policy. If I am unable to keep my scheduled appointment I will give a cancellation notice to the office prior to my appointment time or a $30.00 fee may be assessed. I realize a 24-hour notification is much appreciated. Initial Patient Name (Please Print) Signature of Patient or Responsible Party Date 4
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
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
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM Name: (First) (Middle) (Last) Birth Date: _ Social Security Number: _ Address: _Apartment #: City: State: Zip Code: Home#: Work# Cell#:_ Marital Status: Single Married Divorced
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 INFORMATION. Last Name First Name MI. Address. City State Zip. Cell Phone _( ) Home Phone _( ) May we contact you by ?
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
EYE ASSOCIATES OF MONMOUTH, LLC
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INSURANCE AND MANAGED CARE APPOINTMENT CANCELING POLICY
The physicians and staff of New England Dermatology & Laser Center value and appreciate your selection of our office for your skin care. We are committed to providing you with the best possible service.
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.
Medical History Record
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PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
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Name: Sex: Male Female Date of Birth: / / Age: Home Phone: ( ) - Cell: ( ) -
PATIENT REGISTRATION Name: Sex: Male Female Date of Birth: / / Age: SS# Marital Status: Single Married Widowed Divorced Address City State Zip Home Phone: ( ) - Cell: ( ) - Email: How would you like to
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Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
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6140 W Atlantic Avenue * Delray Beach, FL Tel: (561) * (888) 357-DERM * Fax: (561)
Cosmetic Patient Information Today s Date: Reason for visit: Patient Name: (Last) (First) (Middle) Permanent Address (Local): Street City/State/Zip Secondary (Out of State) Address: Street City/State/Zip
ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
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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Keeping You in Sight 479 Heywood Ave. Spartanburg, SC 29307 Phone: 864-583-6381 Fax: 864-585-7636 www.palmettoeyeandlaser.com Dr. Billy J. Haguewood, Jr. Dr. Brice B. Dille Dr. K. Leanne Wickliffe Dr.
HISTORY INTAKE FORM **CIRCLE ALL THAT APPLY ABOUT YOU**
Name: Date: D.O.B: HISTORY INTAKE FORM **CIRCLE ALL THAT APPLY ABOUT YOU** PAST MEDICAL HISTORY: Anxiety Arthritis Asthma A-Fib BPH Bone Marrow Transplant Breast Cancer Colon Cancer COPD Coronary Artery
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
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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:
Acupuncture & Herbal Therapies
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Immediate Family History Please list Father, Mother, Brother, Sister or Children
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PATIENT REGISTRATION INFORMATION. Please Print
PATIENT REGISTRATION INFORMATION Please Print Dr. Mrs. Ms. Mr. First Name M.I. Last Sex: M F SS# Date of Birth / / Age Marital Status: Married Single Divorced Widowed If married, spouse s name: Mailing
Over. Signature of Patient/Parent/Guardian: Date: / / Date: / / Patient s Name: For ADULT Patients : Employer: Address: Occupation:
Date: / / Patient s Name: Address: Preferred Home: ( ) - Work: ( ) - Cell: ( ) - Text Message Reminders : Yes No Social Security #: Date of Birth: - - / / For ADULT Patients : Employer: Occupation: Spouse
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
New Patient Questionnaire. Name DOB Date
Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol
HEADACHE HISTORY FORM
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NEW PATIENT REGISTRATION FORM
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PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: _( ) Marital Status: Married Single Divorced Widowed Cell Phone:
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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
I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.
1. Patient Rights and Responsibilities Acknowledgement I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference. 2. Notice of Privacy
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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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PATIENT INFORMATION. Name: First Name MI Last Name. Date of Birth: / / Sex: Male / Female / Declined SSN:
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