Medical History
Please fill out this entire form to the best of your knowledge. Thank you.
ASSESSMENT
Race |
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Ethnicity |
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Preferred Language
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Alcohol |
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Smoking Status |
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Height: Ft.
In.
Weight: Lbs.
PG/Nursing
List any hobbies you enjoy:
Review of Systems
Do you have symptoms of: (Please list all that apply)
General Health (good, cold, fever, fatigue, loss of apetite, weight gain, weight loss):
Ear/Nose/Throat (none, chronic cough, congestion, headache, hearing problems, runny nose, sinus problems, sleep apnea):
Cardiovascular Disease (none, arrhythmia, chest pain, heart disease, high blood pressure, high cholesterol, shortness of breath, stroke, swollen feet/ankles):
Pulmonary (none, asthma, chronic cough, COPD, cyanosis, emphysema, shortness of breath, wheezing):
Genitourinary (none, overactive bladder, painful urniation, prostate, underactive bladder, urinary incontinence):
Gastrointestinal (none, acid reflux(GERD), bronzing of skin, constipation, dark urine, diarrhea, jaundice, nausea, vomiting):
Endocrine (none, cold intolerance, diabetes, excess thirst, frequent urination, heat intolerance, hyperthyroid, hypothyroid):
If you have diabetes, please indicate: Year diagnosed:
A1c
Musculoskeletal (none, arthritis, fibromyalgia, joint pain, muscle cramps, stiffness, swelling, weakness):
Skin (none, acne, blisters, cysts, eczema, psoriasis, rash, rosacea, scales):
Neurological (none, cerebral palsy, dementia, epilepsy, memory problems, multiple sclerosis, numbness, tingling, tremors, vertigo):
Psychiatric (none, ADHD, anxiety, depression, hallucinations, insomnia, paranoia, social withdrawal, substance abuse):
Hematological/Lymph Node (none, bleeding, bleeding gums, easy bruising, jaundice, nosebleeds, pale skin, pounding in ears):
Immune (none, AIDS, HIV+, lupus, mild allergy symptoms, redness of skin, severe allergy symptoms, sneezing):
Family History
Has any member of your family been diagnosed with the following:
Ocular History
Have you or any member of your family been diagnosed with the following:
List any eye surgeries/eye injuries: |
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List any other medical history: |
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Submit Data
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COVID-19/HEALTH SCREENING
IN AN EFFORT TO KEEP OUR STAFF AND PATIENTS HEALTHY, PLEASE CALL OUR OFFICE PRIOR TO YOUR
APPOINTMENT, IF YOU WOULD ANSWER YES TO ANY OF THE BELOW QUESTIONS.
Within the last 5 days have you experienced any of the following symptoms:
Fever?
Cough?
Chills?
Sore throat?
IF SOMEONE IN YOUR HOUSEHOLD HAS HAD ANY OF THE ABOVE SYMPTOMS, PLEASE WEAR A MASK WHILE IN OUR
OFFICE.
THANK YOU
I acknowledge that I have read the questionnaire and would answer no to all questions.
Date:
No Show and Cancelation Policy
We schedule our appointments so each patient can spend the necessary amount of time with our doctors and maintain efficiency in
our schedule. If you miss, no show, or cancel your appointment without enough time to refill that appointment spot then you have
effectively taken a spot from another patient.
To help you remember your scheduled appointment, we send text message and email reminders when you make an appointment
and two days before your appointment as well. As a courtesy to our office, as well as to those patients who are waiting to schedule
with the doctor, please give us more than 24 hours' notice if you must cancel.
If you cancel within 24hours of your scheduled appointment time there will be a mandatory fee of
$50.00 cancelation fee. If you
miss/no show for your appointment
OR are more than 15 minutes late for your appointment you will be charged a mandatory
$150.00 missed appointment fee. These fees are not reimbursable by your insurance company and will be directly billed to you.
After three missed appointments, our practice may decide to dismiss you as a patient.
I understand the no-show and cancelation policy of Eye Care Associates and agree to provide payment for appointments that fall
under the above descriptions. I understand that I must cancel or reschedule any appointment at least 24 hours in advance in order
to avoid a potential cancelation/missed appointment fee as outlined above.
Please understand a signature of this form is required to make any appointment at our office.
About Your Vision Care Plan & Your Medical Insurance
There are
two types of health insurance that will help pay for your eye health services and products.
Vision Plans cover ONLY routine vision wellness exams and may include eyeglasses and contact lenses. Vision plans do NOT provide
for MEDICAL EYE HEALTH CARE THAT IS NEEDED. Currently our office accepts only Vision Service Plan (VSP) and Vision Care Direct
(VCD).
Medical Insurance Plans are for any medical eye healthcare diagnosis, treatment care and follow-up. Currently our office is
contracted with Blue Cross Blue Shield and Medicare. If you have medical insurance
other than a contracted insurance, we will do
our best to submit the claim for your reimbursement. However, you will be responsible for payment in full prior to our submitting
your claim for your reimbursement.
If you have both a
Vision Plan and a
Medical Plan, it may be necessary for us to submit and bill some services to one plan provider
and some services to the other plan provider, we will follow a procedure called "Coordination of Benefits" to do this properly and to
maximize your best advantage and least cost to you.
Where some fees for services and products are not paid by your vision plan or medical plan, you will be responsible for them,
including deductibles, co-payments, refractions, contact lens evaluation/fittings and any non-provider services as specified by the
Insurance Contract.
Please provide your vision plan provider and medical insurance card(s) and identification for your records so that we may submit
claims on your behalf.
I have read and accept this office procedure.