Premier Eye Associates

Demographics

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Patient Information

*How did you hear about our practice?

*First	*Last	Nickname

*Address:
*City:		*State/ZipCode

*Cell Phone:
*SSN
*Email
*Birthday
*Occupation
*Sex	Male Female
*Employer / School Name
*Emergency Contact Name, Relation, Number:
Marital Status
Race:

*Is the Billing Address Different?
Yes No

*Is The Patient 18 Or Older? Yes No

*Parent/Guardian Name, Phone, and Social

Vision Insurance

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*Primary Vision Insurance Information
Yes Vision Insurance No Vision Insurance

Insurance Name:
Insurance ID #:

*Primary on Account: Yes Not Primary

Medical Insurance

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*Primary Medical Insurance Information
Yes Medical Insurance No Medical Insurance

*Insurance Name:
*Insurance ID #:
*Group / Policy #:

*Primary on Account: Yes Not Primary

*Secondary Medical Insurance Information
Yes Secondary Medical Insurance No Secondary Medical Insurance

Insurance Name:
Insurance ID #:
Goup / Policy #:

Family History

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Family History

Family Eye History

*Macular Degen:		*Glaucoma:
*Retinal Detach:		*Lazy/Crossed Eye:
*Blindness:

Family Medical History

Unknown family history

Does anyone in your family have any of these medical conditions?

*Diabetes:	Yes No
*High Blood Pressure:	Yes No
*High Cholesterol:	Yes No
*Thyroid Conditions:	Yes No
*Heart Conditions:	Yes No
*Cancer:	Yes No

Medical History

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Patient Medical History

*Do you currently have any of these symptoms?:

*Have you had any eye surgeries? Please describe:

*Medications: Yes (please list) No Meds Used

*Over The Counter Medications: Yes (please list) No Over The Counter Meds Used

*Vitamins: Yes (please list) No Vitamins Used

*Drug Allergies: Yes (please list) No Known Drug Allergies

*Please describe any injuries or surgeries you have had:

*Primary Care Physician:

*Pregnant/Nursing:

Do you have any of these medical conditions?

*Diabetes:	Yes	No
*High Blood Pressure:	Yes	No
*High Cholesterol:	Yes	No
*Thyroid Conditions:	Yes	No
*Heart Conditions:	Yes	No
*Cancer:	Yes	No

Social History

*Smoking Status:	*Type:	How Long:
*Alcohol Use:	*Type:	How Long:
*Illegal Drug Use:	*Type:	How Long

*Race:

*Ethnicity:

*Preferred Language:

Review of Systems

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Do you currently or have you ever had any of the following medical conditions?

*General:	Yes	No	*Ear/Nose/Throat:	Yes	No
*Skin:	Yes	No	*Cardiovascular:	Yes	No
*Respiratory:	Yes	No	*Musculoskeletal:	Yes	No
*Psychiatric:	Yes	No	*Gastrointestinal:	Yes	No
*Endocrine:	Yes	No	*Blood/Lymph:	Yes	No
*Neurological:	Yes	No	*Genitourinary:	Yes	No
*Immune:	Yes	No	*Eyes:	Yes	No

Submit Data

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*Check:
*Patient Signature:
*Date:

Name:	Last, First, MI
Relationship to Primary:	Spouse Child Other
Sex:	Male Female
Birthday:
SSN:

Name:	Last, First, MI
Relationship to Primary:	Spouse Child Other
Sex:	Male Female
Birthday:
SSN:

First	Last	MI	Suffix

City	State	ZipCode