Patient Information and Medical History Form

Patient Information and Medical History Form

Patient Information

Billing Information

General Medical History

Review of Systems

Ocular History

Patient Signatures

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 828-586-8080. We can always change the data in the office if you are unsure about what to enter in any of the fields.

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

Title	First*	Last*	MI	Suffix	Nickname

Address

City	St	Zip

Hm Phone*
Cell Phone*
Wk Phone
Other Phone
SSN
Email
Preferred Contact By
DOB (mm/dd/yyyy)
Sex	Female Male
Marital Status
Spouse's Name
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?

Is The Billing Address the Same?

Title	First	Last	MI	Suffix

Address

City	St	Zip
Hm Phone
Wk Phone

Primary physician's name and phone
When was your last physical exam?
Height:	Ft. In.
Weight:	Lbs.

Check the box for any conditions that apply:

If *YOU* are diabetic, when were you diagnosed?		Last A1C level?
Are you Pregnant or Nursing?

List ALL major injuries or surgeries you have had and approx dates:

List any other medical conditions you have had, including non-drug allergies:

List all Rx and over-the-counter medications you currently take:

List any vitamins or supplements you currently take:

List any drug allergies you have:

Smoking Status
Type
Alcohol Use
Do you live alone?

Please list any problems you are currently having anywhere, from head to toe:

General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain)

Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, sleep apnea, hearing problems)

Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs)

Respiratory (e.g., chronic cough, shortness of breath, wheezing)

Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge, menstrual changes, impotence)

Gastrointestinal (e.g., constipation, diarrhea, gastric reflux (GERD), jaundice, nausea, vomiting)

Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination)

Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements)

Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration)

Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, dementia, speech problems)

Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive)

Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising)

Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes)

Who was your previous eye doctor?
When was your last eye exam?

Check the box for any conditions that apply:

List any major eye injuries, infections or surgeries and approx dates:

List any other significant eye problems you have had:

List all Rx and over-the-counter eye medications you currently use:

List any vision complaints you are currently having such as:

blurred vision, headaches, eyestrain, double vision, or losing your place when reading
itching, burning, redness, pain, sensitivity to light, watering, crusting or mucus discharge
seeing rainbows around white lights at night, flashes of light or dark spots/squiggles/webs

How many hours/day do you typically spend using a computer or other digital devices?
If you are having complaints with computer work, how far is the monitor from your eyes?
How many hours/day do you typically spend reading books, magazines, etc?

What are your hobbies/sports activities?
Do you have sunglasses?
Do you have back-up glassess?
Are you interested in contacts?
Contact Lens Wearers Only
What disinfecting solution do you use?
How long do you usually wear your lenses?
How often do you replace your lenses?
How old is your current pair of contacts?

Dilation Fundus Examination

In order to perform a comprehensive eye examination, dilation should be performed to ensure the best eye care. Only a small portion of the posterior retina can be viewed without dilation. This procedure enables the doctor to examine the eyes for cataracts, glaucoma, and other conditions that may result in vision loss. Early signs of diabetes, arteriosclerosis, and high blood pressure can be detected. In addition, the doctor can examine the retina for any holes, tears, detachments, or tumors. In order to dilate the eyes, drops are instilled which widen the pupils within 10-20 minutes. Your vision, especially reading vision, will become blurred for about 3-4 hours. Dilation also has a tendency to make eyes more sensitive to light, so disposable sunglasses are available to ease the glare from the sun and depending on your personal sensitivity, you may need to avoid driving or operating dangerous machinery for 3-4 hours or until the effects wear off.

YES I would like to have a complete dilated exam.
NO I decline the dilation and understand that I am releasing Dr. Brandy E. Hicks from any liability.

IWellness Exam

Sight threatening diseases such as glaucoma, macular degeneration, diabetic retinopathy, and others often have no outward signs or symptoms, which is why eye exams, including a thorough retinal evaluation, are important to protect vision. In an effort to provide a more thorough eye exam, our practice is pleased to now offer Digital Retinal Imaging as well as the iWellnessExam SD- OCT retinal screening as part of your eye exam today. This unique technology can help detect vision threating diseases in their very early stages, when they are most treatable.

Because knowing the results of this test is so valuable, Dr. Hicks is advising every patient to have this test done yearly to help monitor slight changes and detect eye disease earlier than otherwise possible.

These two tests will become a part of your permanent patient record and will be reviewed with you by Dr. Hicks during your exam today. The $59 charge is typically not covered by your medical or vision insurance unless being used to actively follow disease. This cost will be added into the price of your visit today.

Any questions you have about these tests can be discussed during your examination with Dr. Hicks.

Please perform baseline retinal iWellness screening as an additional procedure to my examination.
I do not wish to have baseline screening performed at this time.

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 Policies And Consent Form, Financial Responsibilities And Consent

View Notice Of Privacy Policies And Consent Form, Financial Responsibilities And Consent

Patient Signature: Date:
Print Name (and relation if parent/guardian):

Describe (type, when were you diagnosed, etc)

Hypertension

Cardiovascular