WELCOME [www.crystalcityeyecare.com]



WELCOME TO CRYSTAL EYE CARE

|PATIENT INFORMATION |

Date: _____/_____/2020

Name: _______________________________________________________________________

Address: ______________________________________________________________________

Apt # City State Zip Code

Phone #s:(Cell / Home): _______________ Work: _______________ Email: ________________

Date of Birth: __________________ Patient’s SS#: _____________________ (required for certain insurances)

Occupation: __________________________ Employer / School: ______________________

Whom may we thank for referring you? ___________________________________________

|EYE HEALTH HISTORY |

Reason for visit: __________________________________________________________

______________________________________________________

Date of last eye exam: _____________ Name of eye doctor/office: _________________________

Do you frequently experience/have (please check all that apply):

□ Blurred Vision – Distance □ Night Vision, Poor

□ Blurred Vision – Near □ Light Sensitivity

□ Distorted Vision □ Floaters or Spots

□ Double Vision □ Seeing Halos

□ Burning Eyes □ Seeing Flashes

□ Itchy Eyes □ Dizziness

□ Watery Eyes □ Headaches

□ Painful Eyes □ Eye Infection

□ Discharge From Eyes □ Excessive Squinting □ Dry Eyes □ Eye Strain

□ Gritty, Sandy Eyes □ Other ________________________

Do you wear prescribed glasses? □ Yes □ No □ Worn before

□ All the time □ Occasionally

□ Reading □ Driving □ TV □ Computer □ Other ________________

How old are your glasses? ___________

Do you presently wear contact lenses? □ Yes □ Occasionally □ No □ Worn before

If so, what type? □ Soft □ Rigid Gas Permeable □ Color □ Not sure

Brand / Prescription of contacts: __________________________________________

Wearing hours / Day: _______________hours / day

Wear contact lens overnight? □ No □ Yes: How Often: ______________________

How often do you replace contact lenses?:___________________________________ ________________________

If you or a blood relative have experienced any of the following, check all that apply and

please indicate who:

□ Glaucoma_________________________ □ Macular degeneration _____________________

□ Loss of Vision______________________ □ Eye Injury______________________________

□ Temporary Loss of Vision _____________ □ Eye Surgery_ ____________________________

□ Cataract __________________________ □ Amblyopia/ Lazy Eye_____________________

□ Retina problem ____________________ □ Color Vision, Poor_______________________

□ Other Eye Diseases _ ______________________________________________________________

* Please fill out the other side

|HEALTH HISTORY |

Physician’s name: _____________________________ Date of last visit: _____________

Dr’s telephone numbers: ____________________________________

Do you have problems with any of these systems? (Please circle all that apply)

Gastrointestinal Y / N Nervous Y / N Eyes Y / N

Ears/Nose/Throat Y / N Genitourinary Y / N Mental Y / N

Cardiovascular Y / N Muscle Y / N Endocrine Y / N

Respiratory Y / N Bone / Joint Y / N Skin Y / N

If you or a blood relative have any of the followings, please

check all that apply and indicate who does:

□ High Blood Pressure________________ □ Hay Fever ________________________

□ Diabetes__________________________ □ Asthma ___________________________

□ Cholesterol______________________ □ Lupus ___________________________

□ Heart Condition____________________ □ Arthritis __________________________

□ Thyroid problems___________________ □ Shingles__________________________

□ Kidney Disease_____________________ □ AIDS/ HIV________________________

□ Skin Conditions_____________________ □ Do you smoke? ____________________

□ Excessive Alcohol use_______________ For female:

□ Others _____________________________ □ Are you pregnant? __________________

| MEDICATIONS | ALLERGIES |

List medications you are currently taking, List your allergies to medications or other

including eye drops. How often are you substances:

taking, and reason for taking? _____________________________________

__________________________________ __________________________________

__________________________________ __________________________________

__________________________________ __________________________________

__________________________________ __________________________________

__________________________________ __________________________________

__________________________________

HIPAA Notice of Privacy Practices

Crystal Eye Care will use and disclose your personal health information to treat you, to receive payment for care we provide and for other health care operations. Health care operations generally include those activities we perform to improve the quality of care. We have prepared a detailed Notice of privacy practices to help you better understand our policies in regard to protected health information. The terms of the notice may change with time. We will post the current notice at our facility and have copies available to distribute.

I acknowledge I have received, read and understand the Notice of privacy practices.

By signing the form, you also agree to responsible for payment of any services not paid by insurance in full, and consider the signature as ‘on file’ for billing insurance purposes.

___________________________________ ________________________

Signature Date of Signature

For Office use only:

□ We, Crystal Eye Care, Dr. Jeff Chuh, OD, made a good faith effort to obtain the patient’s acknowledgement, but the patient did not sign the form today. ____/____/______

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