Dupageoptical- Patient Health History

PATIENT HEALTH HISTORY

Office Use #

Today's date

Date

Last Name:

First Name:

MI:

Address:

Apt #

State:

City:

Zip:

Home Phone:

Format: (000) 000-0000.

Cell Phone:

Format: (000) 000-0000.

Text for notifications

Email Address:

your email address will never be shared

Birth Date:

Date

Gender:

Marital Status:

SS #:

Employer:

Occupation:

Vision Plan:

ID Number:

Medical Insurance Name:

Medical Insurance ID Number:

Physician Name:

Physician Phone #:

Format: (000) 000-0000.

Primary Insurance Holders Name:

Primary's Birthdate:

Date

Primary's Last Digits of SSN #:

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?

Do you wear glasses?

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

Do you wear contact lenses?

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

Type of contact lenses?

Are they comfortable?

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

Blindness

RELATIONSHIP

Cataract

RELATIONSHIP

Glaucoma

RELATIONSHIP

Macular Degeneration

RELATIONSHIP

Thyroid Disease

RELATIONSHIP

Retinal Detachment/Disease

RELATIONSHIP

Arthritis

RELATIONSHIP

Cancer

RELATIONSHIP

Diabetes

RELATIONSHIP

Heart Disease

RELATIONSHIP

High Blood Pressure

RELATIONSHIP

Kidney Disease

RELATIONSHIP

Lupus

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

Date

Our office reserves the right to charge patients for any missed appointment.

Preferred Language:

Preferred Communication:

Race

Ethnicity

MEDICATIONS

Please list all medications currently prescribed.

Do you have any allergies to Medications?

If Yes, explain:

REVIEW OF SYSTEMS

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

Rows	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

Rows	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.

Do you use tobacco products?

If yes, type/amount/how long:

Do you drink alcohol?

If yes, type/amount/how long:

Do you use illegal drugs?

If yes, type/amount/how long:

Have you ever been exposed/infected with:

VERY IMPORTANT! NEW PATIENTS ONLY:

Whom may we thank for referring you to our office? Please print the name.

Dr.

Which Web Site?

MEDICAL HISTORY