Mountain Valley Vision Center



Mountain Valley Vision CenterDavid Czerny OD - Jessica Czerny OD, DVM - Jordyn Stevens OD - Jonathan Nebelsick, OD 1236 North Ave Spearfish SD 57783 605-642-2645 DATE_________________________ Patient Name____________________________ Date of Birth________________ Social Security No._________________Address____________________________________ City ________________State______________ Zip_____________Home Phone_____________________ Work Phone___________________Cell Phone____________________________Occupation__________________Employer_______________________________________________________________Spouse or parent____________________________ Spouses place of employment_______________________________Name of last eye Dr. and date of last exam_______________________________________________________________Referred BY? _____________________________ Patient Email Address______________________________________MEDICAL INFORMATION Do you or have you ever had any of the following? Y N Ears/nose/mouth/throat problems __________________________________________________Y N Constitutional (Fever/Unexplained weight loss/gain)___________________________________Y N Cardiovascular (Heart Disease etc)_________________________________________________Y N Respiratory Disease (ex COPD)__________________________________________________Y N Tuberculosis _________________________________________________________________Y N Gastrointestinal disease (ex Crohn’s)_______________________________________________Y N Genitourinary disease (ex Kidney Disease)__________________________________________Y N Arthritis (specify type) _________________________________________________________Y N Muscle Pain _________________________________________________________________Y N Skin Conditions_______________________________________________________________Y N Headaches __________________________________________________________________Y N Other Neurologic problems (MS etc.)_____________________________________________Y N Psychiatric __________________________________________________________________Y N Endocrine disease (Thyroid etc.) _________________________________________________Y N Diabetes Type_____________________________________________________________Y N Hematologic/lymphatic (ex Blood Disease)_________________________________________Y N Hepatitis A/B/C _____________________________________________________________Y N Have you ever tested positive to HIV or other Infectious Disease (please specify)________________________________________________________________Y N Allergic/Immunologic _________________________________________________________Y N Cancer (specify type) _________________________________Active or Remission? (Circle one)Y N Watery/red/itchy eyes Y N Double VisionY N Dry Eyes Y N Amblyopia (Lazy eye)Y N Floaters/spots Y N Strabismus (Eye turn ) Y N Flashes of lightPERSONAL INFORMATION Are you pregnant or nursing? Y NWeight _________LB Ethnicity: Hisp/Lat Not-Hisp/Lat Decline Height ____FT____IN Race: Afr-Am Cauc Asian Hisp Am- Ind DeclineAny other medical problems not listed above: ____________________________________________________________________________________________________________________________________________________________________________________________________Do you have any medication allergies… If YES what type of reaction Yes/No____________________________________________________________________________________________________________________________________________________________________________________________Are you taking any medications Y N Please list: ____________________________________________________________________________________________________________________________________________________________________________________________________Have you had any operations___________________________________________________________________________________________________________________________________________________________________________Name of family Doctor____________________________________Date of last visit_______________________________Social History Are you a: Current smoker___ b: Never smoker___ C: Previous smoker___(IF you have habitually smoked, How many years?_________Do you drink alcohol Yes/No How much_______________Do you use any other drugs Yes/No___________________ FAMILY HISTORY (list any family members who may have the following)Macular Degeneration Yes/No Relation__________________ Diabetes Yes/No Relation__________________ Glaucoma Yes/No Relation__________________ Heart Disease Yes/No Relation____________________Autoimmune Disease Yes/No Relation__________________ Thyroid Disease Yes/No Relation __________________Other genetic disease Yes/No _________________________PERSONAL EYE INFORMATION_________________________________________________________________________Eye conditions or problems Yes/No_____________________________________________________________________Eye Operations Yes/No________________________________________________Date_________________Eye Injuries Yes/No________________________________________________Date_________________Glaucoma Yes/NoCataracts Yes/NoMacular Degeneration Yes/NoRetinal Detachments Yes/NoHIPAA DisclosureI authorize release of relevant medical information to the following person(s):Name_____________________________________________Relationship____________________________Name_____________________________________________Relationship____________________________SIGNATURE OF PATIENT___________________________________________Signature on file:I acknowledge that a copy of the Notice of Privacy Practices for Mountain Valley Vision Center was made available to meand I authorize the release of information to my insurance companies. I understand that I am responsible for any amount not covered by my insuranceSign_______________________________________________________________Date____________________________Sign_______________________________________________________________Date____________________________Sign_______________________________________________________________Date____________________________Sign_______________________________________________________________Date____________________________ ................
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