American Eyecare Burlington Patient History Form

American Eyecare Burlington Patient History Formadmin2019-05-09T18:30:21+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 Country
Email*
Social Security Number
Gender
- Male
- Female
Birthdate*
MM slash DD slash YYYY
Check the appropriate box:*
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:

Medications	Dosages

Present Illness	Date diagnosed

American Eyecare Burlington Patient History Form

Responsible Party

HIPAA Authorization & Release of Medical Information

Medical Information

Personal/Social History

Review of Organ Systems

Family History