New medical history questionnaire

Medical History Questionnaire
Name: __________________________________________________ Sex: M / F Today’s Date: _______/_______/________ Address:____________________________________________________________ Phone:_____________________________ City:______________________________ Zip:______________________ Work Phone:________________________ Guardian (If Applicable):________________________________________________ Occupation:_________________________ Birth Date:_______/_______/_______ Social Security #:_______/______/_______ Last Eye Exam:_______/_______/________ Email:___________________________________________ Referred here by:________________________________________ Name of Medical Doctor:_______________________________________________ Dr.’s Phone:_________________________
Medical History
Do you have any allergies to medications?  No  Yes If yes, explain:________________________________________
_______________________________________________________________________________________________________ List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies): _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ List all major injuries, surgeries and/or hospitalizations you have had:____________________________________________________ ____________________________________________________________________________________________________________ List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections or eye injury:_____________________________________________________________________________ Are you pregnant and/or nursing?  No  Yes
Do you wear glasses?  No  Yes If yes, how old is your current pair of lenses?___________________________
Do you wear contact lenses?  No  Yes If yes, how old is your current pair of lenses?___________________________
Type of contact lenses:  Rigid  Soft  Extended Wear  Other Are they comfortable? Yes  No
Family History
Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:
DISEASE/CONDITION NO YES ? RELATIONSHIP TO YOU
   ________________________________________________________    ________________________________________________________    ________________________________________________________    ________________________________________________________ Macular Degeneration    ________________________________________________________ Retinal Detachment/Disease    ________________________________________________________ Arthritis    ________________________________________________________    ________________________________________________________    ________________________________________________________    ________________________________________________________    ________________________________________________________    ________________________________________________________    ________________________________________________________    ________________________________________________________ Other__________________    ________________________________________________________
Social History This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.

 Yes, I would prefer to discuss my Social History information directly with my doctor. (Check Box) Do you drive?  No Yes If yes, do you have visual difficulty when driving?  No  Yes If yes, please describe: ____________________________________________________________________________________________________________ Do you use tobacco products?  No  Yes If yes, type / amount / how long:________________________________________ Do you drink alcohol?  No  Yes If yes, type / amount / how long:___________________________________________ Do you use illegal drugs?  No  Yes If yes, type / amount / how long:___________________________________________ Have you ever been exposed to or infected with:  Gonorrhea  Hepatitis  HIV Syphilis
Review of Systems
Do you currently, or have you ever had any problems in the following areas:
SYSTEM NO YES ?

CONSTITUTIONAL
EARS, NOSE, MOUTH, THROAT
INTEGUMENTARY (Skin)
NEUROLOGICAL
RESPIRATORY
Blurred Vision    Chronic Bronchitis VASCULAR / CARDIOVASCULAR
GASTROINTESTINAL
GENITOURINARY
BONES / JOINTS / MUSCLES
Chronic Infection of Eye or Lid    LYMPHATIC / HEMATOLOGIC
ENDOCRINE
ALLERGIC / IMMUNOLOGIC   
PSYCHIATRIC

If you answered YES to any of the above or have a condition not listed, please explain & list medications:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________

____________________________________________________ _____________________
Insurance Information
Subscriber’s Name:__________________________________I.D./SS#_____________________________________ Subscriber’s DOB:______/______/_______ Relation to Patient:______________________________ Vision Insurance Company:____________________________________
Medical Insurance Co.:__________________________________ I.D.#___________________________________
Professional services are rendered and charged to you, not the insurance company. Please understand that any insurance contract is between you and the insurance company and payment for services and materials are your responsibility. We may need to file claims with your medical insurance
company for the diagnosis and treatment of medical conditions not covered by your routine vision benefits. We will accept assignment of claims for primary
eye care and medical insurance. All deductibles and fee amounts not covered by insurance are due at the time of treatment. Our office will not enter into a
dispute with your insurance company over your claim. This is your responsibility and obligation. If, at the end of 60 days, your insurance company
has not paid, you will be held responsible for the entire balance. Upon request, we will supply you with a copy of the claim so that you can
resubmit if necessary. In order to honor any insurance benefits, you must provide insurance identification (i.e. insurance cards, benefits book, etc.), and we
must be able to verify the current benefits available.
I, the undersigned, certify that I (or my dependent) have insurance coverage with_______________________________and assign directly to Sugarloaf Eycare all insurance benefits. Further, despite my insurance coverage, I understand that I am financially responsible for all charges
incurred. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all
insurance submissions.
I HAVE READ AND I UNDERSTAND THE STATEMENTS OUTLINED ABOVE: Signed:________________________________________________Date:_________________________ Authorization for Use or Disclosure of Protected Health Information
I authorize Mitch Christensen, O.D./Christine Laube, O.D. and/or administrative and clinical staff to disclose the following protected information to: Insurance Company:___________________________________ Other:________________________________________ The type of information being released is: date of service, type of service, level of detail, etc. This protected health information is being used or disclosed for the following purposes: 1. At the request of the individual 2. Submitting of claims to insurance companies 3. Hospital or surgical needed information This authorization shall be in force and effect until the time the office records become part of a new and separate entity at which time this authorization to use or disclose this protected health information expires. I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the practice’s Privacy Contact at 6555 Sugarloaf Parkway #305, Duluth, GA 30097. I understand that a revocation is not effective to the extent that my physician has relied on the use or disclosure of the protected health information or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that information or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. My physician will not condition my treatment, payment, enrollment in a health plan or eligibility for benefits (if applicable) on whether I provide authorization for the requested use or disclosure except: 1. If my treatment is related to research 2. Health care services are provided to me solely for the purpose of creating protected health information for disclosure to a third party The use or disclosure requested under this authorization will result in direct or indirect remuneration to my physician from a third party. We will not allow this information to be used by any entity requesting it for marketing purposes. Patient Name (Please Print):_________________________________________ Signature:__________________________________________ Date:_________/________/_________ Representative:______________________________

Source: http://www.sugarloafeyecare.biz/uploaded/2884/8738f02d-d237-482f-aadc-663bb885ef38patientforms_new-medical-history-questionnaire.pdf