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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. Jake P. Bostrom Dr. J. Steve McPhail Name: Mailing Address: City: State: Zip: Home#: Work#: Cell#: Preferred Language: Social Security #: Date of Birth: Ethnicity: Hispanic or n-hispanic (Circle Choice) Medical Primary Insurance Co: Policy: Medical Secondary Insurance Co: Policy: Please Print Patient Information Sex: Male or Female Insurance Information: Appointment Information: Race: Asian African American Caucasian Bi-Racial Other (Circle Choice) Marital Status: Single Married Separated Divorced Widow (Circle Choice) Primary Care Physician: Referring Physician: Spouse/Parent Name: Phone #: Nearest Relative NOT Living With You: Relationship: Insured s Name: Insured s Social Security #: Insured s Date of Birth: Employer: Retired How would you like to receive future appointment reminders: Email Text Phone Call Email Address: Phone #: I request that payment of authorized Medicare and/or other Insurance benefits be made on my behalf to my physician for services rendered to me. I further authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents and/or to other insurance administrators any information needed to determine these benefits or the benefits payable for related services. I also authorize the release of any medical records from any health care provider to this physician for the purposes of providing coordinated healthcare services to me. And I authorize the release of any medical records from this physician to any healthcare provider for coordination of my medical care. Payment in full is required when services are rendered if there is no insurance coverage. You will be responsible for any portion of your bill which is not paid for by your insurance company. Patient Signature: Date: OR Authorized Patient Signature: Signature: Relationship to patient: Date: **Continue to Back**

Keeping You in Sight Patient Name: Date: ID Number: 1. Have you ever been diagnosed with Dry Eye Disease or Ocular Surface Disease? Yes If yes, When? 2. Do you ever experience any of the following symptoms? Redness Scratchy feeling Burning Tired eyes, eye fatigue Foreign body sensation Fluctuating Vision Itching Excess tearing/watering eyes Stringy mucus in or around the eyes Contact lens discomfort 3. Are your symptoms related to or made worse by any of the following factors? Windy conditions Places with humidity Areas that are air conditioned/heated More than 2 hours of computer/pda use per day There are several methods for treating dry eye symptoms: over the counter tears prescription eye drops/ointments massaging your eyelids eyelid cleaners omega-3 fatty acids treatment to unblock Meibomian Glands (Lipiflow) tear duct plugs Tears keep your eyes healthy and comfortable. Your doctor may suggest one or a combination of the above methods to treat your dry eye symptoms. Do any of the following issues concern you? Facial fine lines/wrinkles Crow s feet Laugh lines Acne/blemishes/dark spots Anti-aging skin care Length/fullness of eyelashes Drooping eyelids/brow

MEDICAL HISTORY QUESTIONNAIRE Name: Date of Birth: / / Medical Record # Primary Care Physician Pharmacy: Location(street & city) Medication Allergies: Reaction Severity Past Ocular History: (Please mark all that apply) Overall Healthy Cataracts Optic Neuritis Macular Degeneration Amblyopia (Lazy eye) Diabetic Retinopathy Iritis Glaucoma Dry Eyes Keratoconus Retinal Detachment Ocular Surgeries: (Please mark all that apply) prior ocular surgery Corneal Transplant PRK Vitrectomy Blepharoplasty Retinal Laser Surgery RK Cataract Surgery LASIK Strabismus Surgery (eye muscle surgery) Ocular Significant Illnesses: (Please mark all that apply) Overall Healthy Graves Disease Lupus Sjogrens AIDS/HIV Herpes Multiple Sclerosis Thyroid Problems Diabetes Hypertension Rheumatoid Arthritis Current Eye Medications: (Please list) Systemic Illnesses: history of illnesses Congestive Heart Failure Hepatitis Lung Disease Anemia COPD High Blood Pressure Lupus Arthritis Diabetes High Cholesterol Migraine Arrhythmia Eczema HIV Polymyalgia Asthma Fibromyalgia Kidney Disease Psychiatric Disorder Bleeding Disorder Headache Kidney Stones Skin Cancer Cancer Hearing Loss Liver Disease Stroke Thyroid Disease Menopause General Surgeries / Operations: (Please list) Please continue on the back side of this page

Current Other Medications: (Please list) Infections: (Please mark all that apply) Overall Healthy Cold Sores HIV / AIDS Herpes Zoster / Shingles Hepatitis A / B / C Meningitis MRSA Family History and Relationship to Family Member: Diabetes Stroke High Blood Pressure Glaucoma Lazy Eye Macular Degeneration Cancer Heart Disease Retinal Disease Social History: (Please mark all that apply) Smoking: current every day smoker former smoker never smoked Alcohol Use: Yes If yes how much and how often? Drug Use: Yes If yes what and how often? Review of Systems: (Please mark all that apply) Eyes Previous Surgery Contact Lens Pain Double Vision Glaucoma Cataracts Macular Degeneration Dry Eyes Flashes Floaters Ear, se, and Throat Hard of Hearing Ringing in Ears Vertigo Cardiovascular Chest Pain Dizziness Fainting Spells Shortness of Breath Irregular Heart Beat Difficulty Lying Flat Constitutional Fatigue / Weakness Fever Weight Gain / Loss Respiratory Cough Congestion Wheezing Asthma Gastrointestinal Heartburn Nausea / Vomiting Jaundice / Hepatitus Genito-Urinary Pain / Difficulty Blood in Urine History of Kidney Stones History of STD s Psychiatric Anxiety / Depression Mood Swings Difficulty Sleeping Endocrine Increased Thirst Increased Hunger Increased Urination Increased Sweating Fingernail Changes Blood / Lymphnodes Easy Bruising Gums Bleed Easy Prolonged Bleeding Blood Thinners/Asprin MusculoSkeletal Stiffness Arthritis Joint Pain / Swelling Skin Rash / Sores Lesions Hives / Eczema Neurological Seizures Weakness / Paralysis Numbness Tremors Immunologic Hives Itching

Keeping You in Sight Activity of Daily Living Patient Name: Acct : Please circle Yes or to each question that applies: Have you been bothered by: Yes How Long: Comments: Blurry/Cloudy Vision Yes A decline in vision Yes Sensitivity to light Yes Seeing rings or halos around lights Yes Glare or poor night vision Yes Difficulty driving during the day Yes Difficulty driving at night Yes Seeing road signs Yes Reading newspapers/books Yes Seeing the computer Yes Watching TV Yes Doing fine handwork/puzzles Yes Seeing double Yes

Dry eyes Yes Hobbies: Patient s Signature: Date:

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