- YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES )

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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 1. 9. Dosages and Frequency ARE Necessary 2. 10. 3. PRESCRIPTION EYE DROPS 4. Dosages and Frequency ARE Necessary 5. 1. 6. 2. 7. 3. 8. 4. VITAMINS, SUPPLEMENTS and OVER-THE-COUNTER MEDICATIONS NONE TAKEN 3. 1. 4. 2. 5. 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?

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

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

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: EMAIL ADDRESS: 1 - THANK YOU -

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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

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

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