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Alamo Optometry
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2018-05-29T18:49:44+00:00
Alamo Optometry
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Birthdate
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MM slash DD slash YYYY
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Street Address
Address Line 2
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Name of Parent (if minor)
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Last
Have we examined other members of your family?
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Yes
No
How did you find out about our office?
Who may we thank for referring you to our office?
First
Last
Name of Last Eye Doctor/Office
Date of Last Eye Exam
MM slash DD slash YYYY
Name of Family Physician
*
First
Last
Date of Last Visit to Primary Care Physician
MM slash DD slash YYYY
Occupation
Employer or School
Vision Insurance
*
Vision Service Plan
Eyemed
Medical Eye Services
None
Subscriber Name
*
First
Last
*If no vision insurance, please enter none for the subscriber information.
Subscriber Birthdate
*
MM slash DD slash YYYY
Subscriber Social Security or Policy Number
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Medical Insurance Company
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Subscriber Name
First
Last
Subscriber Birthdate
MM slash DD slash YYYY
Policy ID or Member Number
If Medicare, is it a PPO, HMO, or Medicare Advantage?
PPO
HMO
Medicare Advantage
If Medicare, list supplemental carrier and policy ID
Do you have routine eye exam benefits through your medical insurance?
Yes
No
Do You Wear Eyeglasses?
*
Yes
No
Do You Wear Contact Lenses
*
Yes
No
Are you planning to get eyeglasses/contacts at your visit?
*
Yes
No
What is the primary reason for your visit?
List All Current or Past Eye Diseases, Eye Injuries or Surgeries
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What Is Your General Health Status?
*
Excellent
Good
Fair
Poor
List All Medications You Are Taking
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Medication Allergies
*
Are You Pregnant or Nursing?
*
Yes
No
Do You Use Tobacco Products?
*
Current
Previous
Never
Do You Drink Alcohol?
*
Socially
Daily
Never
Patient General Health
Allergies
Asthma/Respiratory
Blood Disorders
Cancer
Hypertension
Chronic Bronchitis
Chronic Cough
Diabetes
Emphysema
Gastrointestinal Problems
Heart Attack
Stroke
Headaches/Migraines
Musculoskeletal
Kidney Disorders
Neurological
Psychiatric/Mental Health
Rheumatoid Arthritis
Thyroid Disorder
Weight Loss/Gain
None of the Above
Patient Eye Health
*
Amblyopia (lazy eye)
Blurred Vision-Far
Blurred Vision-Near
Burning Eyes
Cataracts
Double Vision
Drooping Eyelid
Dry Eyes
Eye Turn
Flashes/Floaters
Fluctuating Vision
Foreign Body Sensation
Glaucoma
Glare/Light Sensitivity
Itchy Feeling
Infection of Eye/ Lid
Macular Degeneration
Mucus/Discharge
Redness
Retinal Detachment
Tearing/Watery Eyes
Skin Condition
None of the Above
Family History (Family History includes your parents, grandparents, siblings, and your children)
*
Blindness
Cataract
Glaucoma
Diabetes
High Blood Pressure
Cancer
Heart Disease
Thyroid Disease
Arthritis
Retinal Detachment
Stroke
Macular Degeneration
None of the Above
Are there any other important health or eye/vision concerns?
I have read the HIPAA Notice of Privacy:
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I have read the Financial Responsibility Policy:
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Name
First
Last
Date
MM slash DD slash YYYY
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