Dupageoptical- Patient Health History

PATIENT HEALTH HISTORY
Office Use #
Today's date

MonthDayYear
Date
Last Name:
First Name:
MI:
Address:
Apt #
State:
City:
Zip:
Home Phone:
Cell Phone:
Text for notifications

YesNo
Email Address:
your email address will never be shared
Birth Date:

MonthDayYear
Date
Gender:

MaleFemale
Marital Status:

SingleMarriedDivorcedWidowWidowerUnmarried Partners
SS #:
Employer:
Occupation:
Vision Plan:
ID Number:
Medical Insurance Name:
Medical Insurance ID Number:
Physician Name:
Physician Phone #:
Primary Insurance Holders Name:
Primary's Birthdate:

MonthDayYear
Date
Primary's Last Digits of SSN #:
MEDICAL HISTORY
List all Major injuries, surgeries and/or hospitalizations you have had:
List any of the following that you have ever had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections or eye injury:
Are you pregnant and/or nursing?

YesNo
Do you wear glasses?

YesNo
If yes, how old is your present pair of lenses?
Do you wear contact lenses?

YesNo
If yes, how old is your present pair of lenses?
Type of contact lenses?

RigidSoftExtended WearOther
Are they comfortable?

YesNo
FAMILY HISTORY
Please note any family history (parents, grandparents, siblings, children: living or deceased) for the following conditions:
Blindness

NOYES
RELATIONSHIP
Cataract

NOYES
RELATIONSHIP
Glaucoma

NOYES
RELATIONSHIP
Macular Degeneration

NOYES
RELATIONSHIP
Thyroid Disease

NOYES
RELATIONSHIP
Retinal Detachment/Disease

NOYES
RELATIONSHIP
Arthritis

NOYES
RELATIONSHIP
Cancer

NOYES
RELATIONSHIP
Diabetes

NOYES
RELATIONSHIP
Heart Disease

NOYES
RELATIONSHIP
High Blood Pressure

NOYES
RELATIONSHIP
Kidney Disease

NOYES
RELATIONSHIP
Lupus

NOYES
RELATIONSHIP
Other
ASSIGNMENT, RELEASE and HIPAA RULES
I authorize my insurance benefits to be paid directly to DuPage Optical. I assume responsibility for any remaining balance not covered by insurance. I further authorize the diagnosis and treatment by the doctor, and the release of any medical information necessary for proper care. I have read and understand the HIPAA Privacy rules.
Signature

Clear
Date

MonthDayYear
Date
Our office reserves the right to charge patients for any missed appointment.
Preferred Language:

EnglishSpanish
Preferred Communication:

EmailPhoneMail
Race

American Indian or Alaska nativeAsianBlack or African AmericanHispanicNative Hawaiian/Other Pacific IslandWhite
Ethnicity

Hispanic or LatinoNative Hawaiian/Other Pacific IslandNon Hispanic or Latino
MEDICATIONS
Please list all medications currently prescribed.
Do you have any allergies to Medications?

NoYes
If Yes, explain:
REVIEW OF SYSTEMS

Do you currently, or have you ever had any problems in the following areas:

	NO	YES
CONSTITUTIONAL: Fever, Weight Loss/Gain
INTEGUMENTARY (Skin)
NEUROLOGICAL: Headaches
Migraines
Seizures
EYES: Loss of Vision
Distorted Vision/Halos
Loss of Side Vision
Double Vision
Dryness
Mucous Discharge
Redness
Sandy or Gritty Feeling
Itching
Burning
Foreign Body Sensation
Excess Tearing/Watering
Glare/Light Sensitivity
Eye Pain/Soreness
Chronic Infections of Eye or Lid
Sites or Chalazion
Flashes/Floaters in vision
Tired Eyes
ENDOCRINE: Thyroid/Other Glands
LYMPHATIC/HEMATOLOGIC: Anemia
Bleeding Problems

	NO	YES
NOSE, MOUTH, THROAT: Allergies/Hay Fever
Sinus Congestion
Runny Nose
Post Nasal Drip
Chronic Cough
Dry Throat/Mouth
RESPIRATORY: Asthma
Chronic Bronchitis
Emphysema
VASCULAR/CARDIOVASCULAR: Diabetes
Heart Pain
High Blood Pressure
Vascular Disease
GASTROINTESTINAL:Diarrhea
Constipation
GANTOURINARY: Genitals/Kidney/Bladder
BONES/JOINTS/MUSCLES: Rheumatoid Arthritis
Muscle Pain
Joint Pain
ALLERGIC/IMMUNOLOGIC
PSYCHIATRIC

SOCIAL HISTORY

This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if
you prefer.

Yes, I would prefer to discuss directly with my doctor. (CHECK BOX)
Do you use tobacco products?

YesNo
If yes, type/amount/how long:
Do you drink alcohol?

YesNo
If yes, type/amount/how long:
Do you use illegal drugs?

YesNo
If yes, type/amount/how long:
Have you ever been exposed/infected with:

GonorrheaHepatitisHIVSyphilis
YesNo
VERY IMPORTANT! NEW PATIENTS ONLY:
Whom may we thank for referring you to our office? Please print the name.
Another
Dr.
Insurance ListSaw Sign/Building
Web Page:
Which Web Site?
Should be Empty:

MEDICAL HISTORY