Yourlens



2889250-723900Office use only:Dr: ID #: Time: Ins: Exam Type: Copay:ROUTINE / MEDICAL00Office use only:Dr: ID #: Time: Ins: Exam Type: Copay:ROUTINE / MEDICAL26670019050000Date: Name: M FNickname: Address: City: ST: Zip: Social Security #: Birth Date:Your Profession:Home Phone:Cell Phone: Text: Y NWork Phone:Email:Preferred Method of Contact:Name of Medical Doctor:Medical Dr.’s Phone #:Last Eye Exam: mm/yy: Do you wear glasses (including readers)? No____ Yes____ Do you wear contact lenses? No____ Yes____ REVIEW OF SYSTEMSPlease circle if you currently, or have ever had any problems in the following areas:CONSTITUTIONAL Weight Loss/Gain ? ? Fever ? ?NEUROLOGICAL Headaches / Migraines ? ? Seizures MS Lyme ? ? Stroke Brain Aneurysm Brain TumorEYES Blindness ? ? Cataract ? ? Strabismus (Crossed Eyes)? ? Glaucoma ? ? Macular Degeneration ? ? Retinal Detachment/Disease Loss of Vision ? ? Blurred Vision ? ? Distorted Vision/Halos ? ? Loss of Side Vision ? ? Double Vision ? ? Dryness ? ? Mucus Discharge ? ? Redness ? ? Sandy or Gritty Feeling ? ? Itching ? ? Burning ? ? Foreign Body Sensation ? ? Excess Tearing/Watering ? ? Tracking Problems KeratoconusEYES cont. Glare/Light Sensitivity ? ?Eye Pain or Soreness ? ?Chronic Infection of Eye or Lid Frequent Styes ? ? Flashes of Lights Floaters/’Spots’ ? ? Eye Fatigue ? ?ENDOCRINE Diabetes Thyroid ? ? Pituitary ? ? Other Glands ? ? Cholesterol ? ?EARS/ NOSE/ MOUTH/ THROAT Allergies/Hay Fever ? ? Sinus Congestion ? ? Chronic Cough ? ? Dry Throat/Mouth ? ?RESPIRATORY Asthma ? ? Chronic Bronchitis ? ? Emphysema COPD? ? Sleep ApneaVASCULAR/ CARDIO Heart Pain ? ? High Blood Pressure ? ?Vascular Disease ? ?GASTRO-INTESTINAL Diarrhea ? ? Constipation Ulcerative Colitis ? ? Crohn’s IBS / IBDGENITO-URINARY Genitals/Kidney/Bladder ? ?BONES/ JOINTS/ MUSCLESArthritis Rheumatoid Arthritis ? ? Muscle Pain ? Joint Pain Head or Neck Injury? ?LYMPHATIC/ HEMATOLOGIC Anemia ? ? Bleeding Problems ? ?ALLERGIC/ IMMUNOLOGIC ? Lupus ? ?CancerSjogren’s Syndrome Seasonal SKINGrowthRashes?AcnePSYCHIATRIC ?DepressionAnxiety___ Other: ________________________ Are you currently taking any medications (including BCP’s, vitamins, nutritional supplements, etc.) No____ Yes____ List: _____________________________________________________________________________________________________________________________________________________________________________________________________ Are you allergic to any medications? No____ Yes____ List: _________________________________________Do you currently, or have you ever had any eye injuries and/or surgeries? No____ Yes____ List: _________________________________________51371501409700SOCIAL HISTORYI would prefer to discuss my Social History information directly with my doctor. (Check box) Are you pregnant? YesNo Do you use tobacco products?YesNo If yes, amount/how long _____________________ _____ Do you drink alcohol?YesNo If yes, amount/how long __________________________ Do you use illegal drugs? ? YesNo If yes, amount/how long __________________________ Have you ever been exposed to or infected with: ? Gonorrhea ? Hepatitis ? HIV ? SyphilisApproximate Weight: lbsHeight:Ft InWhat are your hobbies: Do you use a computer:YesNo If yes how many hours a day Do you drive:YesNo If yes any concerns regarding your eyes Are you hard of hearing:YesNoFAMILY HISTORY (Please check off each item as it pertains to your parents, grandparents, siblings, children; living or deceased) of: If yes, state relation If yes, state relationCataracts __Yes Diabetes __YesGlaucoma __YesArthritis __Yes Blindness __YesHypertension __YesCrossed Eyes __Yes Cancer (type) __YesLazy Eye __YesCardiovascular __YesRetinitis Pigmentosa__YesKidney Disease __Yes Retinal Detachment __Yes Heart Disease__Yes Macular Degeneration __Yes Sjogren’s Syndrome __Yes Lupus Disease __Yes Thyroid Disease __Yes ___Other:________________________ Please read and sign the following pageMAINE MALL EYE CARESIGNATURE & PRIVACY PAGEPatient's Name (Printed):___________________________ Date: ______________________ ALL patients must read and initial section 2 and 3. Contact lens patients must read and initial section 4. Section 1. Guarantor Information: Name, Phone Number and AddressGuarantor's Name: (REQUIRED IF PATIENT IS A MINOR) __________ __________________ Guarantor's Signature: ______________________________ ____________ ____Guarantor's Address and Phone Number:________________________________ __ _________________________________________________________________________ Section 2. Financial ResponsibilityBy signing this form you are agreeing to pay the portion of the bill which is either not covered or refused by the insurance company. In the event that you do not pay this amount you are responsible for the collection fee assessed. MMEC reserves the right to decline submitting claims to insurance companies we are not participating with. It is your responsibility to know your insurance policy coverage and benefits. You are also responsible for obtaining any referrals that are needed. Initial:___________Section 3. Patient Receipt of Privacy NoticeI hereby affirm that I have received a copy of the Notice of Privacy Practices from Maine Mall Eye Care. Under federal law 104-191, also known as HIPAA, I am entitled to receive a copy of this Notice from my healthcare provider. I understand that my signature on this acknowledgement only signifies that I have received a copy of the Notice, and does not legally bind or obligate me in any way. I understand that I am entitled to receive a copy of the Notice of Privacy Practice from my healthcare provider, whether I sign this acknowledgement or not. Initial:___________Section 4. Contact Lens Information**An annual contact lens exam and fitting are required in order to renew your prescription for contact lenses. The fitting fee is not covered by insurance. Contact lens follow up appointments are included in the cost of the fee for three months from fitting. Training is required for all first-time lens wearers and there is an additional fee for this procedure. Your lenses are a medical device that can only be dispensed with a valid prescription. Initial:___________By signing this form you are indicating that you have read and understood the above information.Signature:______________________________________________________ ................
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