Professional Eyecare Zona Rosa- Patient Forms

Patient Information

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Preferred Eye Doctor Misc/Guardian
Billing Information If The Billing Address Is Different Check This Box & Fill In Below
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:
 

Medical History

After Completing All Forms Submit Final Data on Submit Data Tab

MEDICAL HISTORY

     Date of Last Medical Exam: 

           Name of Medical Doctor: 

                       Doctor's Phone #: 

    What is you general health status? 

          List all medications you are taking: 

     Do you have allergies to medications? 

                                      If yes, to what? 

                                     What happens? 

     Do you have general allergies? 

                             If yes, to what: 

                            What happens? 

     List all major illnesses, injuries, surgeries and/or hospitalizations you have had:
    


      
Ladies:    Are you pregnant?    Are you nursing? 

_________________________________________________________________________________________________________________________________________________________________________________________________________________________

ADDITIONAL INFORMATION  Please fill out the fields below:
           

        Preferred Language: 

                            Race: 

                       Ethnicity: 

                 Height  Feet:  Inches: 

                 Weight (lbs): 

________________________________________________________________________________________________________________________________________

OCULAR HISTORY

          Date of Last Eye Exam? 

         Do you wear eyeglasses? 

    Do you wear contact lenses? 

                                         
If yes, what type? 

        If yes, what solution/care system? 

    List any current eye drops: 

    List any current or past eye diseases, eye injuries or eye surgeries:
   
    List any family members that are patients in our office:
   
________________________________________________________________________________________________________________________________________

* If adopted select yes and move to the Social History section
________________________________________________________________________________________________________________________________________

FAMILY HISTORY
    Please note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions:

                   Disease/Condition   Y/N             Relationship To You
                                Blindness   

                                            Cataract   

                                 Crossed Eyes   

                                Glaucoma   

                 Macular Degeneration   

     Retinal Detachment/Disease    

                                   Arthritis   

                                               Cancer   

        
                                    Diabetes   

                                
Heart Disease   

                    High Blood Pressure   

                                     Stroke   

                        Kidney Disease   

                                     Lupus   

                      Thyroid Disease   

         Other    

________________________________________________________________________________________________________________________________________

SOCIAL HISTORY

   
This information is a protected part of you medical record and is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.

    Does your vision limit activities of daily living? (driving, reading, working, etc.) 

            If yes, please describe: 

    Do you use tobacco products?  If yes, type/amount/how long?  

                 Do you drink alcohol?  If yes, type/amount/how long?  

              Do you do illegal drugs?  If yes, type/amount/how long?  

    Have you ever been exposed to or infected with?

               HIV   Hepatitis   Tuberculosis   Syphilis   Gonorrhea   Chlamydia 


_______________________________________________________________________________________________________________________________________

REVIEW OF SYSTEMS

    Do you currently, or have you ever had any problems in the following areas:


   
CONSTITUTIONAL                                If yes, please explain or describe:
              Fever, Weight Loss/Gain  

    INTEGUMENTARY
                                                    Skin  

    NEUROLOGICAL
                                            Headaches 

                                            Migraines   

                                               Seizures  

    EYES
                               Loss of Vision  

                                    Blurred Vision   

                    
Distorted Vision/Halos   

                     Loss of Side Vision   

                                  Double Vision   

                                      Dryness   

                      Mucous Discharge   

                                      Redness   

                    
Sandy or Gritty Feeling  

                                                        Itching  

                                         Burning  

           
        Foreign Body Sensation  

                 
Excess Tearing/Watering   

                       
Glare/Light Sensitivity   

                        
Eye Pain or Soreness   

        Chronic Eye or Lid Infection   

                             
 Sties or Chalazion   

              
 Flashes/Floaters in Vision   

                                       Tired Eyes  

    ENDOCRINE
                     Thyroid/Other Glands    

    EAR, NOSE, MOUTH, THROAT
                         Allergies/Hay Fever   

                             Sinus Congestion   

                                         Runny Nose   

                                  
Post-Nasal Drip   

                                    
Chronic Cough   

                              
Dry Throat/Mouth   

    RESPIRATORY
                                      Asthma    

                             
Chronic Bronchitis   

                                       
Emphysema      

    VASCULAR/CARDIOVASCULAR
                                              Diabetes    

                                      
Heart Disease   

                         
High Blood Pressure   

                                 
High Cholesterol   

                                
Vascular Disease   

    GASTROINTESTINAL
                                                  Diarrhea   

                                         
Constipation   

    GENITOURINARY
                    Genital/Kidney/Bladder   

    BONES/JOINTS/MUSCLES
                                             Arthritis   

                                          
Muscle Pain   

                                               
Joint Pain   

    LYMPHATIC/HEMATOLOGIC
                              Bleeding Problems   

                                               Anemia   

    ALLERGIC/IMMUNOLOGIC 


    PSYCHIATRIC                        

    If you have a condition not listed please explain or describe it:
   
________________________________________________________________________________________________________________________________________

Medical Insurance

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
If Not The Primary On The Account Check This Box & Fill In Below
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:
 

Vision Insurance

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
If Not The Primary On The Account Check This Box & Fill In Below
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:

Submit Data

After Completing All Forms Submit Final Data on Submit Data Tab