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 Widowed Gender: Male Female Email: Who is the Financially Responsible Party/Primary Insurance Holder? Self Other If Other, provide the following information for the Financially Responsible Party: Name: Relationship: Address: Primary Insurance: Insured Name: Insured Phone: ( ) Relation: Date of Birth: Insured Employer: Insured SS#: ID #: Group/Policy #: Co-pay $ _ Secondary Insurance: Insured Name: Insured Phone: ( ) Relation: Date of Birth: Insured Employer: Insured SS#: ID #: Group/Policy #: Co-pay $ _ I request the insurance carrier or Medicare to pay directly to Maryland Vision Center, PA the amount due for any services rendered. I also agree to pay any amount that the insurance carrier or Medicare deems as not a covered benefit and also any amount the insurance carrier or Medicare determines to be my responsibility. I understand that an EYE Exam includes medical examination of my eyes and often a refraction, which may lead to a glasses prescription. It does not include contact lens fitting, corneal measurements or contact lens specifications. In all cases, professional fees are the responsibility of the patient and/or the stated financially responsible party. I agree to treatment deemed necessary by the physician and authorize the release of any medical information required by the involved parties to be necessary to process this claim. Patient or financially responsible party(ies) further agree to pay any and all collection fees incurred and legal expenses, including but not limited to Collection Agency and Attorney fees, court expenses, service and filing fees. Signature of Patient and/or Financially Responsible Party Date
PATIENT MEDICAL HISTORY FORM Name: D.O.B: / / (First) (Middle) (Last) Primary Care Physician: Referred By: Why were you referred to our practice? ALLERGIES: No Known Drug Allergies LATEX Erythromycin _ Reaction: severe _ Reaction: severe _ Reaction: severe mild/ moderate/ mild/ moderate/ mild/ moderate/ DO YOU HAVE ANY OF THESE EYE SYMPTOMS? (Please mark all that apply) Healthy Overall Blurry distance vision Eye mattering or tearing Eye pain Flashing lights Blurry near vision Itching or burning eyes Dry Eyes Foreign body sensation Constant double vision Growth on eyelids Redness Floaters Glare, halos around lights Other PAST OCULAR HISTORY : (Please mark all that apply) Overall Healthy Serious eye/head trauma Cataracts Hyperopia (Far sighted) Lazy Eye Macular Degeneration Glaucoma Myopia (Near sighted) Astigmatism Diabetic Retinopathy Keratoconus Amblyopia (Lazy eye) Optic Neuritis Retinal Detachment Dry Eyes Iritis/uveitis Other Do you wear: Glasses Contacts For: Distance Reading If Contacts: Dailies Extended Wear Gas Permeable Years of usage: _
PLEASE LIST ANY EYE SURGERY YOU HAVE HAD: (Including dates) CURRENT EYE MEDICATIONS: OTC Artificial Eye Drops 1 2 3 4 5 at bedtime 1 2 3 4 5 at bedtime 1 2 3 4 5 at bedtime CURRENT GENERAL Rx & OTC MEDICATIONS: (Please list Name /Dosage) SYSTEMIC ILLNESSES: (Please mark all that apply) Overall Healthy Diabetes Type: _ Anemia Eczema Thyroid Disease Sjogrens Rheumatoid Arthritis Arthritis High Cholesterol Stroke Bleeding Disorder HIV Positive/AIDS Arrhythmia Fibromyalgia Liver Disease Polymyalgia Hypothyroidism Asthma Kidney Disease Graves Disease Multiple Sclerosis Hyperthyroidism COPD Psychiatric Disorder Hearing Loss Lung Disease High Blood Pressure Migraine Headache Arrhythmia Kidney Stones Lupus Congestive Heart Failure
Cancer Type: Other_ GENERAL SURGERIES/OPERATIONS: (Please list) FAMILY HISTORY: (Please mark all that apply) Diabetes Kidney Disease Macular Degeneration Cataracts Cancer Stroke Blindness Retinal Disease High Blood Pressure TB Arthritis Lazy Eye Glaucoma Heart Disease Other: HISTORY OF INFECTIONS: (Please mark all that apply) Herpes Simplex HIV / AIDS Syphilis Wound Infection Chicken Pox Herpes Zoster / Shingles Meningitis Toxoplasmosis Hepatitis A / B / C Histoplasmosis MRSA Chlamydia SOCIAL HISTORY: (Please mark all that apply) Alcohol Use: Yes No If yes how much and how often? Smoking: current every day smoker current some day smoker former smoker never smoked Drug Use: Yes No If yes what and how often? REVIEW OF SYSTEMS (ROS): (Please mark all that apply) GENERAL- Weight loss or gain Fatigue Fever or chills Weakness Trouble sleeping SKIN- Rashes Lumps Itching Dryness Color changes Hair and nail changes HEAD- Headache Head injury Neck Pain
EARS- Decreased hearing Ringing in ears Earache Drainage NOSE- Stuffiness Discharge Itching Hay fever Nosebleeds Sinus pain THROAT- Bleeding Dentures Sore tongue Dry mouth Sore throat Hoarseness Thrush Non-healing sores NECK- Lumps swollen glands Pain Stiffness BREAST- Lumps Pain Discharge Self-exams Breast-feeding RESPIRATORY- Cough Sputum Coughing up blood Shortness of breath Wheezing Painful breathing CARDIOVASCULAR- Chest pain or discomfort Difficulty breathing lying down Tightness Palpitations Swelling Shortness of breath with activity Sudden awakening from sleep with shortness of breath GASTROINTESTINAL- Swallowing difficulties Heartburn Change in bowel habits Nausea Leg cramping Rectal bleeding Constipation Diarrhea Yellow eyes or skin Change in appetite URINARY- Frequency Urgency Burning or pain Blood in urine Incontinence Change in urinary strength VASCULAR- Calf pain with walking MUSCULOSKELETAL- Muscle or joint pain Stiffness Back pain Redness of joints Swelling of joints Trauma NEUROLOGIC- Dizziness Fainting Seizures Weakness Numbness Tingling Tremor HEMATOLOGIC- Ease of bruising Ease of bleeding ENDOCRINE- Head or cold intolerance Sweating Frequent urination Thirst Change in appetite PSYCHIATRIC- Nervousness Stress Depression Memory loss. Signature of Patient Date:
Please initial by each statement. ACKNOWLEDGMENT: RECEIPT OF NOTICE OF PRIVACY PRACTICES I have read/received a copy of Maryland Vision Center s Notice of Privacy Practices effective 10/25/2013. OR I am a parent or legal guardian of (patient name). I have read/received a copy of Maryland Vision Center s Notice of Privacy Practices effective 10/25/2013. CANCELLATION POLICY We understand that there are emergencies and obligations that may cause you to miss a scheduled appointment. If you are not able to make an appointment we require that you notify us at least 24 hours in advance. If you reschedule, no-show, or cancel 3 consecutive appointments without proper notification you may be discharged from our care. REFRACTION NOTICE _ Refraction is an important part of your eye exam and helps determine if a new prescription for glasses will help improve your vision. Refraction is a service not commonly completed by our practice, however if necessary or requested we can complete this service for you. NOT ALL PATIENTS RECEIVE THIS SERVICE. This service may not covered by your medical insurance and we do not bill vision insurance. If you would like a new prescription for glasses, or if the doctor thinks that it is medically necessary, there is a $40.00 fee. We require ALL patients to sign our Refraction Notice. I understand and agree to all of the statements I have initialed above. Printed Name: Signature: Date: _