PATIENT INFORMATION QUESTIONNAIRE



Last Name: _______________________First________________ M.I.____Today’s Date: ____________________Nickname:_______________________ (Gender: M F ) Occupation:______________________Address: ____________________________________________________ Home Phone:_____________________City: _______________________ State: __________ Zip: _________ __ Cell Phone:_______________________Date of Birth: ____/____/____ SSN_______-_______-________Work Phone: _____________________Parent/Guardian (if applicable)_________________________________E-Mail:___________________________Primary Care physician: _____________________________________Last Eye Exam: ___________________Referred by:_________________________________________________HIPAA Notice and AcknowledgementI acknowledge that I have been provided the HIPAA Notice of Privacy Practices ___Yes ____NoChief Complaint: What is your primary reason for this visit? _____________________________________________________________________________________________________________________________________________Are you experiencing any of the following ocular or visual symptoms? (Check all that apply)Blurred Vision____Light Sensitivity____Reduced Night Vision____Burning Eyes____Itchy, Watery Eyes____Reduced Side Vision____Excessive Tearing____Dry, Gritty Feeling____Halos around Lights____Noticeable Redness____Pain or Discomfort____Flashes or Flickers____Double Vision____New Floaters/Spots____ Loss of Vision ____Have you ever been diagnosed with, or treated for, any of the following ocular conditions?Retinal Detachment____Ocular Infections____Lazy or Turned Eye____Cataracts____Glaucoma____Styes, Inflamed Lids____Macular Degen.____Disease of Retina____Do you now wear glasses?________If so, how old are they? _________________________How is your vision with them? _____________Are they comfortable? _________________What type? ____ Readers ____Distance____ Bifocal____ Trifocal____ProgressiveATTENTION CONTACT LENS PATIENTS:A contact lens fitting is a professional service separate from the routine vision exam. The fitting includes the trial lenses and any follow-up appointments to provide you with a contact lens prescription. By signing below, you acknowledge that you can use your insurance benefits to cover the contact lens fitting, OR you will pay for the contact lens fitting at the time of service.Signature (patient/ responsible party)____________________________________________________ Date________________Do you currently wear contact lenses?________ What type/brand?________________________ Hours per day?____________Do you use a computer?__________________How many hours per day? __________________Any previous surgeries or injuries to your eyes?_________ If so, please describe_________________ __________________________________________________________________________________Using any ocular medicines?________Please list if known: ______________________________What hobbies, activities, and/or sports do you enjoy? _______________________________________Would you be willing to provide feedback to us on your experience today via a text message or e-mail survey? ____Yes ____NoMedical History:Do you have any allergies to medicines?_________If so, please list: _________________________________Are you taking any Rx or OTC medicines?_________If so, please list: ____________________________________________________________________________________________________________________________________Any previous injuries, surgeries, or hospitalizations? _____________________________________________________________________________________________________________________________________________________Are you pregnant or nursing?__________ If pregnant, list due date:___________________________________Have you been diagnosed with or treated for any of the following problems? (Check all that apply)Allergy Food ____ Seasonal____GenitourinaryMusculoskeletalCardiovascular Bladder Infection____ Arthritis ____ Heart Problems____ Kidney Stones____ Joint Pain ____ High Blood Pressure____Cranial/Facial Muscle Pain ____Constitutional Chronic Cough____Neurological Fever____ Dry Mouth ____ Headaches ____ Weight Gain____ Sinus Infection____ Migraines ____ Weight Loss____ Ear Infection____ Seizures ____ Dizziness/Fainting____ Hearing Loss____ Bell’s Palsy ____EndocrineHematologic/Lymphatic CP/MS/MD/MG ____ Diabetes____ Anemia____ Psychiatric Thyroid Disorder____ Clotting/Bleeding Depression ____ Elevated Cholesterol____ Disorders____ ADD/ADHD ____GastrointestinalImmunologic Alzheimers/Dementia___ Gastrointestinal Disorder____ HIV/AIDS____ Respiratory Hepatitis____ Syphilis ____ Asthma ____ Gall Bladder____ Lupus____ Chronic Bronchitis ____ Ulcers____ Mononucleosis____ Emphysema, COPD ____ Shingles____ Tuberculosis ____Social History:Do you drive?____yes ____NoIf yes, are you having any visual difficulties? ____________________Do you use tobacco products? ____Yes ____NoIf so, how often? ________________________________Do you use alcohol? ____Yes ____No If so, how often? ___________________________________________Do you have a history of drug or alcohol abuse? ____Yes____No If yes, how long? _________________Have you ever been exposed to HIV or other sexually transmitted diseases? ____Yes ____NoFamily Medical History:In your immediate family, is there any history of the following conditions?Blindness: Injury___ Disease____Relationship: ___________________________Turned or Lazy Eyes ____ Relationship: ___________________________Cataracts ____Relationship: ___________________________Glaucoma ____Relationship: ___________________________Macular Degeneration ____Relationship: ___________________________Retinal Detach/Disease ____Relationship: ___________________________Arthritis ____Relationship: ___________________________Cancer ____Relationship: ___________________________Diabetes ____Relationship: ___________________________Heart Disease ____Relationship: ___________________________High Blood Pressure ____Relationship: ___________________________Kidney Disease ____Relationship: ___________________________Lupus ____Relationship: ___________________________Thyroid Disease ____Relationship: ___________________________Patient Insurance InformationVision Plan or Medical Insurance being billed today:Primary’s Name: ____________________________________ Primary’s DOB: ______/______/_________Name of Plan or Insurance: __________________________Primary’s Employer: __________________Member ID or SSN Number: __________________________Group Number: ______________________Medical Consent to TreatmentThe doctor at Active Eyecare of Surprise is licensed to provide both routine vision exams and medical eye exams. If you are here today for a routine vision exam and your complaint or initial assessment indicates that there is a significant medical condition that requires treatment, you will be either provided with appropriate treatment today; referred to the appropriate specialist for treatment; or rescheduled for a medical examination. Active Eyecare is not a contracted provider for medical visits so the charges for your visit will be payable at the time of service. The doctor will discuss any such condition with you prior to initiating medical treatment, and it is your responsibility to consent to treatment or request referral to the appropriate specialist.Acknowledgements and SignatureI acknowledge that the health and insurance information I have provided above is true and correct to the best of my ability. I authorize payment of any vision or medical benefits I may be eligible for directly to Active Eyecare of Surprise. I agree that if my employer, insurance carrier, or plan sponsor denies payment to all or any part of my claim, I will be financially responsible for all outstanding charges. I acknowledge that authorization obtained at the time of service does not guarantee payment, and any services not covered by insurance will be billed to me. In the event it becomes necessary to place any unpaid balances I am responsible for in collection, I agree to pay any collection fees, reasonable attorney fees, filing fees, and other costs the court determines are proper. I have read the conditions of service, and as the Patient or the Patient’s Authorized Representative I hereby accept these terms.Signature of Patient or ________________________________________________ Date: __________________Responsible Party ................
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