1. Healthcare

PATIENT INFORMATION
Thank you for choosing our practice for your eye care needs. Please print and complete the form front
and back. Once you have completed this form, please return along with your driver’s license and
insurance card (if applicable).
Today’s Date: __________________
Name: _______________________________________________ Title _______ Dr. Mr. Mrs.
Nick Name: __________________________
Miss
Age: ________ Date of Birth: _________________
Address: _________________________________ City: _____________ State: _____ Zip ________
Cell phone # ____________________Work phone # _________________Home phone # ____________
Social Security # _____________________________
Driver’s License # ____________________
You or your parent’s employer: __________________________ Occupation: _____________________
Spouse or Parent’s name: _______________________________________________________________
E-mail: _____________________________________________________________________________
Whom may we thank for referring you to our office? _________________________________________
INSURANCE INFORMATION
Vision Insurance _________________________ Health insurance: _____________________________
Primary Member’s Name: ______________________ Birth date: __/__/____ SS #: ________________
Relationship to Primary Member: ____________________ Spouse or parents name: _______________
PERSONAL EYE INFORMATION
Do you feel a change in your prescription to see clearly at: Distance? __________ Near? __________
Date of last eye exam: ______________________ Doctor or location: __________________________
Do you have any eye conditions or problems? __________ What kind? __________________________
Have you had any eye operations? _________ Type: __________________
When? ___________
Have you had any eye injury? _________ Type: _____________________
When? ___________
Do you experience any eye strain? (i.e. pain, occasional spots, twitching eyelids) _____ When? ___________
Have you ever received visual training (eye exercises)? ______ When? __________________________
Do you have any of the following?
_____ Glaucoma
_____ Cataracts
_____ Dry Eyes
_____ Macular Degeneration
_____ Headaches- when do you get them? _____________________ Where do you hurt? __________
Do you wear glasses? ________ When do you wear your glasses? ______________________________
Have you ever worn contact lenses? ______ When were they prescribed? ________________________
Do you wear contact lenses now? ________ If not, why did you quit? ___________________________
What type of contact lenses? _____________ Are you interested in wearing contact lenses? __________
PLEASE TURN OVER
CONFINDENTIAL
MEDICAL INFORMATION
What is your general health? ____________________________________________________________
Date of your last general health exam? ____________ Any Abnormalities reported? ________________
Who is your primary care physician? _____________________________________________________
Do you have problems with any of the following/systems?
_____ Allergies
_____ Arthritis
_____ Asthma/Respiratory
_____ Cardiovascular
_____ Diabetes
_____ Ears/nose/throat
_____ Endocrine (glands) _____ Gastrointestinal
_____ High blood pressure
_____ Integumentary
_____ Lupus
_____ Muscles/bones
_____ Nervous
_____ Thyroid disease
_____ Urinary
Please Explain: _______________________________________________________________________
Other health problems: _________________________________________________________________
Do you smoke? ______________________________________________________________________
Are you currently taking any medications? ______ Type: ____________________________________
Are you taking any hormones, including Birth Control pills? __________ Type: __________________
Are you allergic to any medications? _____ Explain: ________________________________________
Have you had any operations? ________
Type: ________________________ When? ___________
FAMILY HISTORY
Does anyone in your family have a history or the following?
_____ High Blood Pressure
_____ Diabetes
_____ Macular Degeneration
_____ Cataracts
_____ Wear Glasses
_____ Eye Disease
_____ Tuberculosis
_____ Blindness
_____
_____
_____
_____
Glaucoma
Heart Disease
Wear Contact Lenses
Turned or Lazy Eye
CERTIFICATION AND ASSIGNMENT
To the best of my knowledge, the above information is complete and correct. I understand that is my
responsibility to inform my doctor if I, or my minor child, ever have a change in health.
I certify that I, and/or my dependent(s), have insurance coverage with ___________________________
Name of Insurance Company
And assign directly to Eye Care Associates all insurance benefits for services rendered. I understand
that I am financially responsible for all charges not covered by insurance, as well as, any copayments at
the time of the visit. I authorize the use of my signature on all insurance submissions.
The above-named doctor may use my health care information and may disclose such information to the
above-named Insurance Company and their agents for the purpose of obtaining payment for services and
determining insurance benefits or the benefits payable for related services. This consent will end when
my current treatment plan is completed or one year form the date signed above.
________________________________________________________________
Signature of Patient, Parent, Guardian or Personal Representative
__________________
Date
________________________________________________________________
__________________
Please print name of Patient, Parent, Guardian or Personal Representative
Relationship to Patient