communityeyecare-tx.com - New Patient Form

WELCOME TO COMMUNITY EYE CARE
Name

First NameMiddle NameLast Name
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth

MonthDayYear
Date
Age
SSN
Sex

MaleFemale
Marital Status

SingleMarriedDivorcedWidowed
Work Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Cell Phone
Please enter a valid phone number.
Email Address
example@example.com
Occupation (or Grade):
Employer (or School):
If minor, PARENT/GUARDIAN print name:
Who may we thank for telling you about our office?
PERSONAL EYE HISTORY
What is the reason for your visit today?
Do you have any of the following problems?

Eye Irritation/InfectionGlareFloaters/FlashesBlurred VisionEye ItchinessHeadachesOther
When was your last eye exam? (Approximately):
Do you wear GLASSES?

YesNo
If yes, do you have them with you TODAY?

YesNo
When do you wear your GLASSES?

Full TimePart TimeReadingDistance/DrivingComputer UseSafetyOther
Describe your computer use:

Extensive (5+ hrs/day)Moderate (1-4 hrs/day)Low (1hr/day or less)Never
Had any EYE SURGERY?

NoneLasikRKCataractRetinaGlaucomaEyelidOther
Do you wear contact Lens ?

YesNo
Lens Type:

Soft DisposableSoft YearlyColorRGP (Hard)MonovisionBifocal/MultifocalFor Astigmatism
If you know the Brand and Power of your contacts please indicate:
Do you sleep with your CONTACTS?

YesNo
How often do you replace your lenses?
How old are the contacts you are currently wearing?
Do you have problems with dryness when you wear your contacts?

YesNo
Do you have an eye infection?

YesNo
Which eye?

BothRight eyeLeft Eye
For how long?.
What have you done to treat your eye(s)?
Name any drops you used:
Did something get into your eye?

YesNo
PERSONAL MEDICAL HISTORY

Many general medical conditions affect the eye and your vision
Do you take any prescription or non-prescription medicines regularly?

YesNo
If yes, please list all medicines:
Do you have any medication allergies?

None knownPenicillinSulfa DrugsOther
Do you have problems with the following systems? (Please check all that apply in each box)
Constitutional

NoneWeight LossFatigueTraumaFeverCancerOther
Allergic/ Immunologic

NoneDrug allergyEnvironment allergyRheumatold arthritisLupusOther
Cardiovascular

NoneHeart DiseaseStrokeVascular diseaseHigh Blood PressureHigh Cholesterol
Genitourinary

NoneUrinary tract infectionsKidney concernsSTD: Herpes, Chlamydia, HIV
Ears, Nose & Throat

NoneUpper respiratory tract infectionOther
Neurological

NoneMultiple sclerosisEpilepsyOther
Endocrine

NoneType 1 DiabetesThyroid DysfunctionType 2 DiabetesHormonal DysfunctionOther
Blood/Lymphatic

NoneAnemiaLeukemiaOther
Psychiatric

NoneDepressionPanic DisorderSchizophreniaOther
Gastrointestinal

NoneCrohn's diseaseColitisUlcerDigestive concernOther
Musculoskeletal

NoneFibromyalgiaMuscularOsteoarthritisOther
Integumentary/ Skin

NoneEczemaRosaceaPsoriasisOther
Respiratory

NoneAsthmaBronchitisOther
Please check this box if you DO NOT have any medical conditions.
FAMILY MEDICAL HISTORY

Is there any family medical history or any of the following? (If yes, please list their relationship to you)

	Yes	No	Relationship
None
Blindness
Corneal Disease
Cataracts
Lazy Eye
Glaucoma
Diabetes
Macular
Heart Disease
Retinal
Other Eye Disorders

Social History

	Yes	No
Use tobacco?
Alcoholic Beverages?
Are you pregnant?
Breastfeeding?

Insurance Information Release
When making a third party claim, I authorize the release of my medical Information to process my third party claim. I authorize Community Eve Care Trey Stafford, 0.D. to file complaints on my behalf if my third party carrier does not properly handle my claim. I authorize the release of any information to pertinent to my case to any third party, adjuster, or attorney involved in resolving the financial status of my account. I authorize my third party plan to pay community eye care/Trey Stafford, 0.D. directly.

IF MY PLAN DOES NOT PAY THIS CLAIM, I AGREE TO BE RESPONSIBLE FOR THE PAYMENT OF THESE PROFESSIONAL SERVICES.
Signature

Clear
Date

MonthDayYear
Date
Acknowledge of Privacy and Voluntary Consent Form
In providing services to you, we create, receive, and store health information that identifies you. It is often necessary to use and disclose this information in order to treat you and conduct health care operations involving our office. The Notice of Privacy Practices posted in our office describes these uses and disclosures in detail. Please refer to this notice any time prior to signing this Consent Form. Copies are available for your personal documents.
I have read this Receipt and Consent Form and understand it. I consent to the use and disclosure of my health information for purposes of treatment, payment and healthcare options.
Signature

Clear
If you are signing as a personal representative of the patient, please indicate your relationship to the patient and write your name.
Relationship to Patient
Date

MonthDayYear
Date
Should be Empty:

WELCOME TO COMMUNITY EYE CARE

PERSONAL EYE HISTORY

PERSONAL MEDICAL HISTORY

Do you have problems with the following systems? (Please check all that apply in each box)

FAMILY MEDICAL HISTORY