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Maine Optometry – Standish
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2022-12-06T14:11:23+00:00
Maine Optometry - Standish
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Patient Registration
PATIENT:
*
First
M.I.
Last
Address
Street Address
City
State
Zip
Home Phone
Home Phone
Cell Phone
E-mail
Birth Date
MM slash DD slash YYYY
Age
Social Security #:
OCCUPATION:
Employer
OCCUPATION:
Employer
Name of previous eye doctor
Approximate date of last visit
Primary Care Physician
Insurance
STUDENTS:
School
Teacher
Grade
IF UNDER 18:
Father’s name
Mother’s name
YOUR OCULAR HISTORY – Past & Present
Do you wear eyeglasses?
No
Yes:
If yes,
Distance
Near
For what?
Do you wear contact lenses?
No
Yes:
If yes,
Soft
Hard (gas permeable)
Brand:
Have you worn contacts in the past?
No
Yes:
If yes,
Soft
Hard (gas permeable)
How long ago?
PLEASE CHECK ALL THAT APPLY:
Watery Eyes
Eyestrain
Frequent Loss of Place While Reading
Optic Neuritis
Shimmering / Geometric Lights
Black Outs / Vision Loss
Itchy Eyes
Eye Pain
Poor Reading Comprehension
Iritis / Uveitis
Flashing Lights
Dry Eyes
Double Vision
Fluctuating Vision
Floating Spots
Reduced Color Vision
Blurred Vision:
Distance
Near
Right
Left
History of a Turning Eye:
Right
Left
Surgery to Straighten an Eye:
Right
Left
Patching an Eye:
Right
Left
Cataract Surgery?
Right
Left
Cataracts:
No
Yes
Glaucoma:
Macular Degeneration:
Eye Injury:
How long?
How long?
What?
Please list any additional information about your eyes:
Notice of Privacy Practice
I acknowledge that I was offered a copy of MAINE OPTOMETRY P.A. Notice of Privacy Practices
Signature:
Date:
MM slash DD slash YYYY
PLEASE COMPLETE THE REST OF THIS FORM SO WE CAN BETTER SERVE YOUR EYE CARE & EYEWEAR NEEDS
PLEASE CHECK ALL THAT APPLY TO YOUR PERSONAL HEALTH
CARDIOVASCULAR:
Chest Pain
Heart Disease
High Blood Pressure
High Cholesterol
Irregular Heartbeat
Pacemaker
Other
If other, what?
ADDITIONAL INFORMATION:
CONSTITUTIONAL:
Chronic Fatigue
Frequent Dizziness
Other
If other, what?
ADDITIONAL INFORMATION:
EAR, NOSE & THROAT:
Chronic Sinus Infection
Chronic Ear Infection
Hearing Loss
Other
If other, what?
ADDITIONAL INFORMATION:
ENDOCRINE:
Diabetes Type I
Diabetes Type II
Thyroid Disorder
Other
How long?
Average blood sugar:
Fasting:
HbA1c reading:
If other, what?
GASTROINTESTINAL:
Crohn’s Disease
Irritable Bowel
Other
If other, what?
ADDITIONAL INFORMATION:
GENITOURINARY:
Kidney Disorder
Menopausal
Pregnant
Prostate Disorder
Other
If other, what?
ADDITIONAL INFORMATION:
HEMATOLOGY/ ONCOLOGY:
Cancer
No
Type:
Approximate date of diagnosis:
ADDITIONAL INFORMATION:
IMMUNOLOGIC:
Lupus
Multiple Sclerosis
Sarcoidosis
Other
If other, what?
ADDITIONAL INFORMATION:
INTEGUMENTARY:
Eczema
Rosacea
Other
If other, what?
ADDITIONAL INFORMATION:
MUSCULOSKETAL:
Fibromyalgia
Muscular Dystrophy
Rheumatoid Arthritis
Trauma/Injury
Other
What/When?
If other, what?
ADDITIONAL INFORMATION:
NEUROLOGICAL:
Headaches
Migraines
Numbness/Tingling
Stroke
Other
If other, what?
ADDITIONAL INFORMATION:
PSYCHIATRIC:
Anxiety
Dementia
Depression
Other
If other, what?
ADDITIONAL INFORMATION:
RESPIRATORY:
Asthma
Emphysema
Persistent Cough
Shortness of Breath
Tuberculosis
Other
If other, what?
ADDITIONAL INFORMATION:
Do You Smoke?
Yes
No
If yes, for how long?
FAMILY HISTORY
Blindness
Cataracts
Color Vision Problems
Glaucoma
Macular Degeneration
Misaligned Eyes
Retinal Tear/Hole/Detach
Who was diagnosed?
MEDICATIONS:
ALLERGIES:
Signature:
Date:
MM slash DD slash YYYY
Patient Privacy Form
I agree to the privacy policy.
By signing below, I give Maine Optometry, P.A. my permission as the Patient/Legal Guardian/ POA to release my Personal Health Information (PHI) in accordance with established H.I.P.A.A laws for the following:
To release any information regarding my diagnosis and care to my primary care physician (PCP) and any other physicians involved in managing my conditions
To act on my behalf regarding any and all contact with my insurance carrier(s) and also to release any information regarding my diagnosis and care with the primary insurance carrier and any other supplemental insurance carriers
To bill my Insurance company for any services which I have received and understand that regardless of my Insurance status, I am ultimately responsible for any balance on my account. It is also my responsibility to obtain any necessary referrals in a timely manner (3-5 days) from my PCP. If Maine Optometry, P.A. does not receive my referral, I will be responsible for the full payment of services provided. I further understand that any payment due that is delinquent past 30 days is subject to a $15.00 per month billing charge.
By signing I am also aware that any balance due over 90 days may be reported to the Maine Credit Bureau Reporting Service. And that I've been informed that I will be notified by Maine Optometry, P.A. prior to reporting my delinquent account and that the delinquency will stay on my financial record for 7 years.
I also understand that any diagnosis found to be medical in nature during any examination/follow up that it will be sent to my medical insurance provider and that if during my routine preventative eye exam any medical diagnosis (i.e. Cataract, Dry Eye Syndrome, Allergies, Glaucoma etc.) are found, that my routine exam may be considered medical and will be sent to my medical insurance provider for coverage regardless or any vision specific coverage.
Patient Name (Please Print)
First
Last
Patient/Legal Guardian/POA (Please Sign)
Date:
MM slash DD slash YYYY
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