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Advantage Eyecare New Patient
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2017-07-06T01:14:25+00:00
Advantage Eyecare New Patient Form
Today's Date
MM slash DD slash YYYY
Name
First
Middle
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Date of Birth
MM slash DD slash YYYY
Sex
Male
Female
Home Phone
Work Phone Number
Cell Phone
Is it okay to TEXT reminders for appointments or to notify you that your order is in?
Yes
No
Email
** Emails will be used to confirm appointments, notify of orders, to notify of special promotions and to pass along eye health information.
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Native Hawaiian/other Pacific Island
Race
White
Asian
Black
Language Preference
English
Spanish
Family Members that are patients
Name
Do they live with you?
Date of birth
Relationship
Insurance Information
Who is the cardholder of the insurance?
Date of birth
MM slash DD slash YYYY
Employer
Cardholder Social Security
Address of Cardholder
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
If not the same as the patient
Cardholder's Phone Number
Cardholder's Alternate Phone Number
Your Ocular History
Cataracts
Cataract Surgery: Left Eye
Cataract Surgery: Right Eye
Cataract Surgery: Both Eyes
Glaucoma
Lazy Eye
Eye Injury
Eye Disease
Eye Surgery
Other
Date of Cataract Surgery on Left Eye
MM slash DD slash YYYY
Date of Cataract Surgery on Right Eye
MM slash DD slash YYYY
Date of Cataract Surgery on Both Eyes
MM slash DD slash YYYY
Describe your eye injury
Describe your eye disease
Describe your eye surgery
Describe your "Other" ocular history
Family History
Cataracts
Lazy Eye
Macular Degeneration
Glaucoma
Other Eye Diseases
Diabetes
Cancer
Describe your Family History of "Other Eye Diseases"
Please Specify the type of Cancer in your Family History
Please Describe any Other Conditions in your Family History
List your current medications
Name of medication
Dosage
Taken how often?
Reason prescribed
If you take more than one medication, please use the plus symbol to the right of the field to enter more.
List your medication allergies
If you have more than one non-medication allergy, please use the plus symbol to the right of the field to enter more.
List other Non-Medication Allergies
Review of Systems
Cardiovascular
Angina
Arrhythmia
Arterioscierosis
Cardiovascular Disease
Coagulation Disorder
Congestive Heart Disease
Elevated Cholesterol
Endocarditis
Heart Murmur
Heart Palpitations
High Blood Pressure
Mitral Valve Prolapse
Heart Attack
Stroke
Constitutional
Appetite (Excess)
Appetite (Loss)
Anemia
Blackouts
Car sickness
Chills
Colds
Constipation
Coughing
Cramps
Disorientation
Dizziness
Fainting
Fatigue
Fever
Growth (Excess)
Hunger (Excess)
Nausea
Night Sweats
Nosebleeds
Sleep (irregularly)
Sweating
Thirst (Excess)
Vomitiing
Weight gain
Weight loss
persistent symptoms of:
Hematologic/Lympatic
Anemia
Breast Carcinoma
Cavernous Sinus Thromb
Coagulation Disorder
Hematologic Disorder
Hodgkins Disease
Leukemia
Lymphatic Cancer
Pernicious Anemia
Polycuthemia
Sickle Cell Disease
Temporal Arteritis
Thalassemia
Varicose Veins
Endocrine
Cholesterol
Crohn's Disease
Diabetes
Diabetic Suspect
Hperlipoproteinemia
Hypoglycemia
Pituitary Disorder
Renal Disease
Hyperthyroidism
Thyroid Disorder
Type of Diabetes
How many years have you had diabetes
Genitourinary
Amnorrhea
Bladder Infections
Pregnancy: Ectopic
Impotence
Kidney Stones
Menopause
Ovarian Cyst
Ovarian Tumor
Plevic Inflammatory Disease
Prostate Disorder
Prostate Cancer
Sexually Transmitted
Syphilis
Uterine Cancer
Gastrointestinal
Acid-Reflux Syndrome
Alcoholism
Cancer: Colon
Cancer: Liver
Cancer Other
Cirrhosis
Colitis
Diarrhea
Diverticulosis
Gall Bladded
Gall Stones
Gardner's Syndrome
Gastritis
Gastroenteritis
Gastroenteritis Reflux
Heptatitis
Hepatic Disease
Hiatus Hernia
Inflammatory Bowel
Intestinal Obstruction
Jaundice
Pancreatitus
Ulcer Duodenal
Ulcer Stomach
Whipple's Disease
Head
Chronic Cough
Dental Disorder
Dry Mouth
Ear Infection
Encephalitis
Gingivitus
Headaches
Headaches (Cluster)
Headaches (Migraine)
Head Colds
Hearing loss (full)
Hearing loss (impaired)
Meniere's Syndrome
Sinusititus
Integumentary
Acne
Acne Rosacea
Albinism
Atopic Dermatitis
Basal Cell Nevus Syndrome
Cicatricial Pemphigoid
Contact Dermatitis
Dermatitis
Dry Skin
Erythema Mutiforme
Erythema Nodosum
Hermangioma
Hypertrichosis
Impetigo
Immunologic
Acquired Immunodeficiency
AIDS
Bacterial Infection
Chicken Pox
Cytomegaloivirus Infection
Diphtheria
Endophthalmitis
Herpes Simplex
Herpes Zoster
Histolasmosis
HIV positive
Influenza
Lyme Disease
Measles
Mononucleosis
Molluscum Contagiosum
Mumps
Newcastle Disease
Reye's Syndrome
Rheumatic Fever
Rubella
Sarciudisus
Sjorgen's Syndrome
Staphylococcus Infection
Streptococcus Infection
Syphiis
Tetanus
Tuberculosis
Viral Infection
Respiratory
Asthma
Asthma, excercise induced
Bronchitis
Cancer, Lung
COPD
Cystic Fibrosis
Emphysema
Lund Disease
Lung Cancer
Pneumonia
Pulmonary Insufficiency
Respiratory Disfunction
Sarcoidosis
Smoker (Heavy)
Tuberculosis
Musculoskeletal
Ankylosing spondylititiis
Arthriis
Arthritis Rheymatoid
Down's Syndrome
Marfan's Syndrome
Musualr Dystrophy
Myasthenia Gravis
Osteoporosis (Early)
Osteoporosis (Advanced)
Paget's Disease
Polymyalgia Rheumatica
Sacroilitis
Scoliosis
Skeletal Disorder
Tuberculosis
Neurological
Bell's Palsy
Brain Damage
Brain Tumor
Cerebral Palsy
Dyslexia
Encephalitis
Epilepsy
Headache
Headache (Cluster)
Headache (Migraine)
Horner's Syndrome
Hysteria
Malingering
Muscular Dystrophy
Multiple Sclerosis
Myathenia Gravis
Neuraigia
Neurofibromatosis
Nystagmus
Olfactory Disorder
Ophthalmolegia
Parkinson's Disease
Seizure Disorder
Spinal Cord Injury
Sturge-Weber Syndrome
Trigeminal Neuralgia
Tuberous Sclerosis
Vertigo
Von Hippel-Lindue Disease
Psychiatric
Attention Disorder (ADD)
Alcoholism
Alzheimer's Disease
Anorexia
Anxiety Disorder
Autism
Bi-Polar Disorder
Brain Damage (Trauma)
Bulimia
Delusions
Dementia
Depression
Drug Dependency (Current)
Drug Dependency (Past)
Illusions
Insomnia
Learning Disablity
Memory Loss (short-term)
Mentally Challenged
Mental Retardation
Mood Disorder
Orientation Disorder
Personality Disorder
Schizophrenia
Psychiatric Disorder
Suicidal Ideation
Are you a smoker?
Yes
No
If you are a smoker, how much, and how long have you smoked?
How much?
How long?
Have you ever smoked?
Yes
No
How long ago did you quit smoking?
I authorize Dr. Rutan to release to my insurance carriers, including Medicare, Medicaid, and Medicare Supplements to provide any information required to resubmit any denied or incorrectly paid claims. This authorization remains in effect until withdrawn by me
*
Signature
Date
MM slash DD slash YYYY
I acknowledge that I received a copy of Charles H. Rutan O.D.'s Notice of Privacy Practices
Signature
Date
MM slash DD slash YYYY
Name of person responsible for the account
First
Last
Date of birth
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Social Security Number
Relationship to patient
Phone Number
Signature
*
Date
MM slash DD slash YYYY
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