Cherry Hills Family Eyecare

Patient Information and Medical History Form

Thank you for using our secure online forms. Please fill out as much information as you can. When you are finished be sure to hit the submit button at the bottom of the form. If you have any questions, please call us at (636) 273-6336. We can always change the data in the office if you are unsure about what to enter in any of the fields.

Patient Information

*required (first and last name and either a home OR cell phone)

TitleFirst*Last*MISuffixNickname/Preferred Name
Address  
City St  Zip
Hm Phone*
Cell Phone*
Wk Phone
Other Phone
Email
Preferred Contact By
DOB (mm/dd/yyyy)  
Sex Female Male
Marital Status
Employment Status Employed FT Student PT Student
Occupation/Grade
Employer/School
Parent/Guardian
Race
Ethnicity
Preferred Language

Who may we thank for referring you to our office?  

Billing Information

Is The Billing Address the Same?

TitleFirstLastMISuffix
Address
City St  Zip
Hm Phone  
Wk Phone

Primary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Tertiary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

VISUAL HISTORY

Briefly describe the main reason for having an examination: 

Location:   Duration: 

Severity:   Timing:   Context: 

Modifying factors: 

Associated: Do you have any other symptoms related to this?

Other eye issues or problems:


CORRECTIVE LENS HISTORY

   I currently wear glasses:  Full-time  Part-time    If Part-time, how often/when? 
I currently wear contacts:  Full-time  Part-time    If Part-time, how often/when? 
 Soft   Rigid Gas Permeable
Contact Lens Wearers: Are your lenses comfortable?  Yes   No   Current Brand: 
What solution do you use?   What is your replacement schedule? 
How old is your current pair? 
Please list all over-the-counter and prescription eyedrops you use:    How Often Used? 


MEDICAL HISTORY / REVIEW OF SYSTEMS

List all medications you are currently taking (including any OTC/vitamins):

List any medications you are allergic to:


Are you pregnant or nursing?  Yes   No    If yes, what is the due/birth date? 

YES NO YES NO YES NO
Migraines Arthritis High blood pressure
Multiple Sclerosis Allergies/Hay fever Stroke
Diabetes Asthma Anemia
Thyroid problems Emphysema Cancer

Any other condition? 

Do you have?  Hepatitis  HIV  Sexually Transmitted Diseases

PRIMARY CARE PHYSICIAN

Primary Care Physician's Name: 
 Last Visit Date:  

HEALTH HISTORY

Allergies/Alerts:


Do you have any other symptoms related to this? 

General Health History:


Other eye issues or problems:


EYE HISTORY

Do you have a history of any of the following?     Are you currently experiencing any of the following?
YES NO YES NO YES NO
Blindness Headaches Eyes Tear
Eye Turn (Strabismus) Lazy Eye (Amblyopia) Keratoconus
Glaucoma Cataracts Flashing Lights
Frequent Styes Eyes frequently red Eyes Burn
Retinal Detachment Loss of Side Vision Double Vision
Eyes feel dry Eyes "Hurt" or "Tired" Blurred Vision
Floaters Bothered by light/sun Eyes Itch 
Macular Degeneration Eyes feel sandy/gritty Halos around lights

List any eye surgeries:

Describe any eye injuries:

How many hours a day do you use a computer? 
Describe any visual symptoms from computer use: 
Are you interested in information about LASIK? 

FAMILY EYE HISTORY    Family history is unknown/adopted

Any history of the following in any family members (parents, grandparents, siblings, children)?
YES NO RELATIONSHIP TO PATIENT YES NO RELATIONSHIP TO PATIENT
Poor Vision Cataracts
Blindness Diabetes
Eye turn (Strabismus) High Blood Pressure
Lazy Eye (Amblyopia) Stroke
Glaucoma Thyroid Disease
Macular Degeneration   Other Inherited Disease  
Retinal Detachment/Disease Cancer 

Other eye disease or condition:


SOCIAL HISTORY

How often do you smoke/use tobacco products?   How often do you consume alcohol: 

Occupation: 

Who can we thank for referring you to our office? 
If not referred, how did you hear about Cherry Hills Family Eyecare? 



COVID - 19 Patient Waiver

Valued patient: Our office is committed to providing quality eye care with friendly personal service in as safe an environment as we can reasonably provide. In order to help protect you from COVID-19 exposure, we have taken measures such as using additional Personal Protective Equipment, taking extra disinfecting steps, screening patients, controlling patient flow and allowing extra time for procedures. All of these will help to minimize exposure to the virus. However, NO facility of any kind, including this one, can guarantee that you will not encounter the COVID-19 (Coronavirus). Therefore your acceptance of the concurrent risk involved and that you will hold harmless Cherry Hills Family Eye Care, its doctors and staff, suppliers, vendors and all other persons associated directly or indirectly with this eye care facility in the event that you believe you contract or are even exposed to the virus here.

Please Check That You Accept The Above Agreement:

Optomap Form

As part of each comprehensive eye examination, our doctors would like all patients to have a digital image of the retina with the scanning digital imaging system. The retinal scan allows evaluation for many eye diseases such as macular degeneration, glaucoma, retinal holes, retinal detachments, diabetic retinopathy, tumors, and many more diseases without dilation, for most patients.

Early detection is crucial!

The additional cost of this evaluation is $35.00.

The Optomap (digital image of the retina) will be performed as part of every comprehensive examination UNLESS the test is declined by the patient.

Yes

Insurance Notification

Welcome to Cherry Hills Family Eye Care. Thank you for choosing us for your eye care needs. We are delighted to have you as a patient and appreciate the confidence you placed in us. Please take a moment to complete the following information. Any information we already have on file will appear on this form. If you have any questions, please do not hesitate to ask.

Please Read:

In order to control the cost of billing, we ask that the patient's portion is paid at the time services are rendered unless other arrangements are made in advance. We would rather control billing costs than be forced to raise our fees. All professional services and material are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance. Accounts 90 days old are subject to collection fees. There will be a service charge on all returned checks.

Payment from my insurance is to be paid directly to Cherry Hills Family Eye Care. I understand that will be billed as my primary insurance. I understand that billing any secondary insurance is my responsibility. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made when the claim is processed.

Patient Signature:

Privacy Practices Notice

Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

Notice of Privacy Practices

View Notice of Privacy Practices Form

Patient Signature:

I agree to receive a copy of my prescription digitally.

You're Done! Please hit the Submit button below.