Medical History Record

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Transcription:

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 Phone Cell Phone Work Phone Employer Occupation Emergency Contact Phone Number of Last Eye Exam Name of Previous Eye Doctor Name of General Physician Physician s phone number Please check YES or NO Are you prone to fainting? Are you sensitive to dilation drops? Are you pregnant or planning? Are you taking blood thinners? Do you have any of the following? If YES please check box. Dry Eyes Eye Surgeries Wear Glasses Blurred Vision Eye Injuries Wear Contacts Any eye problems at this time? Please explain Are you interested in laser vision correction? Are you interested in glasses, contact lenses, or both? Glasses Contacts Both Please sign below that you have reviewed all information above and it is correct to the best of your knowledge. Signature

Current and Past Medical History (Please check all that apply and indicate when diagnosed) Anxiety Arthritis: Osteoarthritis Rheumatoid arthritis Asthma Atrial Fibrillation Bone Marrow Transplant BPH Cancer (Type: ) COPD Coronary Artery Disease Depression Renal Disease GERD Hearing Loss Hepatitis _ Hypertension (High Blood Pressure) HIV/AIDS Hypercholesterolemia (High Cholesterol) Hyperthyroidism Hypothyroidism Leukemia Lymphoma Radiation Treatment Seizures Stroke Past Surgical History Appendix (Appendectomy) Bladder (Cystectomy) Breast Cancer Colon Gallbladder (Cholecystectomy) Heart Joint Replacement Kidney Liver Ocular History Allergic Conjunctivitis Blepharitis Cataract Contact Lenses Corneal Dystrophy Diabetic Retinopathy Dry Eyes Glasses Glaucoma Macular Degeneration Macular ERM Please explain: Narrow Angles Ocular Hypertension Opthalmic Migraine Pseudoexfoliation Retinal Tear Strabismus PVD Vitreous Floaters 1

Ocular Surgery Blepharoplasty (Eyelid) Cataract Surgery Corneal Transplant DSAEK Eye Muscle Surgery Intravitreal Injections Lasik LPI LTP PRK Ptosis Repair Punctal Plugs Strabismus Surgery Retinal Laser Trabeculectomy Tube Shunt YAG Capsulotomy Family History Blindness Cancer Cataracts CVA Glaucoma Heart Disease Hypertension Retinitis Pigmentosa Macular Degeneration Migraine Retinal Detachment Strabismus Medications (Please list all current medications including over the counter medications.) Name of Medication Dosage 2

Allergies Aspirin Bee stings Nickel Codeine Peanuts Iodine Penicillin Latex Sulfa Social History Smoking How Much: _ Alcohol How Much: _ Drug Use IV Drug Use Drives in Daytime Drives at Night Exercise Caffeine Use Do you have any of the following? Poor Vision Eye Pain Tearing Redness Jaw Pain Scalp Tenderness Loss of Vision Fever Chills Weight Loss Stuffy se Ear Ache Cough Dry Mouth High Blood Pressure Rapid Heart Beat Congestion Wheezing Shortness of Breath Joint Pain Stiffness Arthritis Headache Seizure Stroke Paralysis Anxiety Depression Insomnia Thyroid Abnormalities Bleeding Anemia Allergies Hay Fever Hives Flashes (Eye) Floaters Dizziness 3

Professional Vision of Bel Air Patient Consent Form Our tice of Privacy Practices provides information about how we may use and disclose protected health information about you. The tice contains a Patient Rights section describing your rights under law. You have the right to review our tice before signing this consent. The terms of our tice may change. If we change our tice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction but if we do we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPPA). The patient understands that: Protected heath information may be disclosed or used for treatment, payment or health care operations. The Practice has a tice of Privacy Practices and that the patient has the opportunity to review this tice and receive a paper copy of this tice. The Practice reserves the right to change the tice of Privacy Policies. The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions. The patient may revoke this Consent in writing at any time and all future disclosures will then cease. The Practice may condition treatment upon execution of this Consent. Please complete the list of phone numbers where we can contact you. Reasons for our needing to contact you include but are not limited to the need to confirm or change appointments, to discuss insurance or payment situations, to respond to your inquiries, etc. In using these numbers, we may talk directly with you or leave a message on an answering machine. Phone numbers where Professional Vision may contact me: (Home) (Cell) (Work) (Other) PRINT PATIENT NAME Signature Relationship to patient (if other than patient) Office Representative initials I give permission for you to release my information to the following (Name, Relationship & Phone Number):

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