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DATE______________WELCOME TO OUR OFFICELast Name________________________ First Name______________________ M.I___ Age___ Sex___Address_______________________________Apt.____City__________________State______Zip______Cell #__________________Home #_________________E-mail_____________________________Occupation_____________________________________________Work#_______________________ Employer______________ Employer Address_________________ Marital Status_____ D.O.B_________________How did you hear about our office? (Please Circle) Friend, Family, Insurance, Newspaper, Magazine, Walk/ Drive by, Coupon, Doctor:_________________ Other:_________________________________Family Physician:__________________________________________ Spousal Information: Name_____________________ Occupation:___________________ Work#_______________________ Employer:___________________Eye History: Do you wear (circle): None Glasses Contact Lenses BothPLEASE CIRCLE ANY CONDITION YOU HAVE PRESENTLY OR HAVE HAD IN THE PAST:Dry EyesGlaucomaCataractsMacular DegenerationRetinal Detachment Keratoconus Other___________________________PLEASE CIRCLE ANY CONDITION YOUR FAMILY MEMBER OR BLOOD RELATIVE HAVE PRESENTLY OR HAVE HAD IN THE PASTCataracts Dry Eyes Glaucoma Keratoconus Macular DegenerationRetinal Detachment Other___________________________ General Health History: Is this your first eye exam? Yes / No Are you Pregnant? Yes/ No/ N/APlease circle any condition you have presently or have had in the past: (Circle Condition)No known medical condition___High?Blood?Pressure Heart?Problem Arthritis Lung?Problems Stroke Thyroid?Problems Diabetes: Yes/No If Yes Specify Type: ____________ LDL Ulcers Cancer Others:_________________Circle Conditions your family/blood relative have presently or have had in the past: (Circle Condition)No known medical condition___High?Blood?Pressure Heart?Problem ArthritisLung?Problems Stroke Thyroid?Problems Diabetes: Yes/No If Yes Specify Type: ____________ LDL Ulcers Cancer Others:_________________Annual colorectal cancer screenings___ Received flu vaccine___ Received Pneumococcal Vaccine___ Receiving annual mammogram___ High-risk for cardiac events on aspirin prophylaxis___ Falls: Risk Assessment___ Counseling for Nutrition/Diet___ Counseling for Physical Activity___Reviews of systems: (Circle Condition)Seasonal AllergiesHay FeverChest Pain Congestive Heart Failure Irregular RhythmFeverWeight LossRashSkin DiseaseVomiting UlcersDiarrheaBloody StoolsGenital UlcersDischargeKidney Stones Blood in Urine Sinus Problems Post Nasal DripRunny NoseDry Mouth Hearing Loss Headache MigrainesParalysis FeverJoint Ache Cough BronchitisShortness of BreathAsthmaEmphysema COPD SOCIAL HISTORY: Smoker: Yes/NoSmoke (cigarettes, cigars, pipe) _____#per day/___Years Recreational Drugs Y/N Alcohol (beer, wine, liquor) _____ socially ____Daily ____NeverMedications: Yes/No Include Name/Dosage (Mg)/ How many times daily_______________________Do you Have any Allergies to any Medications?______________________________________________Sx/ Procedures:___No Surgeries___Ocular SurgeryType/Date/Physician________________________________________________Type/Date/Physician___________________________________________________Other SurgeryType/Date/Physician________________________________________________Type/Date/Physician________________________________________________I understand and agree that (regardless of my insurance status), I am ultimately responsible for the balance of my account for any professional services rendered. I understand if there should be any legal action required to obtain any balances I will be responsible for all legal fees. I authorize to release any information and records to any insurance company, adjuster, attorney or insurance commissioner. I authorize and request payment of medical benefits, including Medicare benefits, be made on my behalf to the practice for professional services and treatment rendered. If your insurance requires a referral, it is your responsibility to obtain the referral for your appointment. If not, you will be billed for the visit.Lifetime Signature on File__________________________________________________ Date_________ ................
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