Helfrich Family Eye Care

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Birthdate*

Email*

Sex*

Marital Status*

Home Phone

Cell Phone*

Business Phone

Occupation

Employer

Insurance Company*

Member Name*

First Last

Member DOB*

Member Number*

Secondary

Name of Insured-2

First Last

Member Number-2

Medical Doctor*

First Last

Doctor's Phone

How Did You Find Out About Our Office*

List All Medications You Are Taking*

Have you ever worn:*

Approx. Date of Last Eye Exam

Family History (parents, grandparents, siblings)*

Family History: Other

Social History*

Social History: Other

Medical History: Constitutional*

No
Fever, Weight Loss/Gain
Pregnant/Nursing

Medical History: Integumentary*

No
Skin

Medical History: Neurological*

No
Headaches
Migraines
Seizures

Medical History: Endocrine*

No
Thyroid
Other Glands

Medical History: Ears, Nose, Throat, Mouth*

No
Sinus Congestion
Runny Nose
Chronic Cough
Dry Throat/Mouth

Medical History: Respiratory*

No
Asthma
Bronchitis
Emphysema

Medical History: Vascular, Cardiac*

No
Diabetes
High Blood Pressure
Heart
Vascular Disease

Medical History: Gastrointestinal*

No
Diarrhea
Constipation

Medical History: Genitourinary*

No
Genitals/Kidney/Bladder

Medical History: Musculoskeletal*

No
Arthritis
Muscle Pain

Medical History: Lymph/Hematologic*

No
Anemia
Bleeding Problems

Medical History: Psychiatric*

No
Psychiatric

Medical History: Allergies*

No
Penicillin
Eye Drops
Sulfa
Novocain
Codeine

Medical History: Cancer*

No
Yes

Cancer: Other

If Yes, Type of Cancer

Medical History: Other

Eyes

Eyes: Other

Injuries/Surgeries/Hospitalizations*

No surgeries, injuries, or hospitalizations
LASIK Surgery
Cataract Surgery
Heart Surgery
Other

Injuries/Surgeries/Hospitalizations: Other

Have you had your flu shot this year?*

Yes
No

Untitled

Our office requires payment at the time of service unless we "accept assignment" on your insurance. You are responsible if your insurance does not pay. Contact lens fittings are billed separately from your eye exam. I authorize the release of any medical or other information necessary to process this claim. I also request payment of insurance benefits to the party who accepts assignment below. Your information is protected by our privacy policy. I have received a copy of Helfrich Family Eye Care "Notice of Privacy Practices."

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Date