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Seal Beach Eyes
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2017-07-06T01:14:31+00:00
Seal Beach Eyes Optometry
Patient Information
Name
*
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*
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*
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*
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Sex
*
Female
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Panama
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Sweden
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Thailand
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Tonga
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Tunisia
Turkey
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Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
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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
*
Employment
*
Full Time
Part Time
Occupation
Company
Education
Full Time Student
Part Time Student
Medical History
Name of Family Doctor
Date of Last Visit
Medication Allergies
Non Medication Allergies
*
Current Medications (Including Eye Drops)
*
AIDS/HIV
*
Yes
No
Ears/Nose/Throat
*
Yes
No
Heart Disease
*
Yes
No
Asthma
*
Yes
No
Thyroid Condition
*
Yes
No
Kidney Disease
*
Yes
No
Stroke
*
Yes
No
Cancer
*
Yes
No
Headaches
*
Yes
No
Cigarettes/Tobacco
*
Yes
No
Alcohol
*
Yes
No
Pregnant
*
Yes
No
High Blood Pressure
*
Yes
No
Cataracts
*
Yes
No
Operations/Surgery
*
Yes
No
Other Health Problems
*
Yes
No
Description of Other Health Problems/Date of Surgery-Operations
*
Personal Eye Information
Name of Previous Doctor
Date of Last Exam
Glasses
*
None
Reading
Distance
Computer
Bifocals (Line)
Trifocals
Progressives (No Line)
Contact Lenses
*
Soft Lenses/Disposables
RGP
Conventional
None
Type/Brand
*
BC
DIA
Blurred Vision
*
Yes
No
Dry Eyes
*
Yes
No
Floaters or Spots
*
Yes
No
Double Vision
*
Yes
No
Itchy Eyes
*
Yes
No
Watering Eyes
*
Yes
No
Eye Injury
*
Yes
No
Eye Operation
*
Yes
No
Explain Injury/Operation
*
Insurance
Medical Insurance Plan
*
Medicare
BlueCross
BlueShield
Aetna
Vision Insurance Plan
*
VSP
MES
EyeMed
HIPAA ACKNOWLEDGEMENT
*
Health Insurance Portability and Accessibility Act – ACKNOWLEDGE OF NOTICE OF PRIVACY PRACTICE It is often necessary to use and disclose health information that identifies you in order to treat you, to obtain payment for our services, and, to conduct healthcare operations involving our office. The Notice of Privacy Practices describes these uses and disclosures in detail. Our office is in full compliant with HIPAA, and a copy of the Notice of Privacy Practice is available if you’d like a copy for your records.
Please read and check the box if you have understood and accept this notice of privacy
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