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American Eyecare Burlington Patient History Form
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2019-05-09T18:30:21+00:00
American Eyecare Burlington Patient History Form
Date
MM slash DD slash YYYY
Name
*
First
Last
Phone
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email
*
Social Security Number
Gender
Male
Female
Birthdate
*
MM slash DD slash YYYY
Check the appropriate box:
*
Minor
Single
Married
Divorced
Widowed
Separated
Patient's or parent's employer
Work Phone
Business Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Person to contact in case of emergency:
*
First
Last
Phone
Responsible Party
Name of person responsible for this account:
*
First
Last
Relationship to the patient:
*
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Home Phone:
Birthdate
MM slash DD slash YYYY
Financial Institution:
Employer:
Work Phone
Is this person currently a patient of our office?
*
Yes
No
HIPAA Authorization & Release of Medical Information
I authorize release of any information concerning myself, or my child's health care, advice, and treatment provider for the purpose of evaluation and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me, be made directly to the doctor(s) today and in the future. I acknowledge that I was offered/received a copy of American Eyecare's Notice of Privacy Practices. (If patient is under guardianship, legal guardian should sign as well.)
Signature of patient or parent/guardian if a minor.
*
Medical Information
Personal/Social History
Occupation:
Visual demands?
*
Distance
Reading
Computer
Welding
Power tools
High speed objects
Are you pregnant or nursing?
*
Yes
No
Do you smoke?
*
Yes
No
Alcohol Consumption
Social only
Alcohol consumption: Number per day
Have you ever been infected with a communicable disease?
*
Yes
No
If yes, please explain:
Review of Organ Systems
Known medical conditions
No known medical conditions
Thyroid/Hormone/Glands
Neurological
Lymphatic/Hematological
Ear/Nose/Throat
Collagen-vascular disorders
Respiratory
Stomach/Intestine/Colon
Bone/Joint/Muscle
Genital/Bladder/Kidney
Psychiatric
Skin diseases/disorders
Eye health conditions
Family Medical Doctor
*
First
Last
Pharmacy:
*
Medication Allergies
*
Current Medications/Dosages:
*
Medications
Dosages
Present Illness (chronic & acute)/Date diagnosed
*
Present Illness
Date diagnosed
Family History
Please list your blood relatives that have been diagnosed with the following:
Blindness:
Cataract:
Crossed eyes:
Glaucoma:
Macular degeneration:
Retinal detachment:
Cancer:
Diabetes:
Heart disease:
High blood pressure:
Kidney disease:
Lupus:
Thyroid disease:
Other:
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