New Patient History Form - Lifetime EyeCare

Name

Today's Date *

Last Eye Exam

Doctor

Last Name *

First Name *

Preferred Name

Sex *

Date of Birth *

Address *

City *

State *

Zip Code *

SSN *

Phone *

Phone Type *

Email *

Marital Status *

Occupation *

Hobbies

Employer / School *

Name of Spouse or Guardian

Emergency Contact *

Emergency Contact Phone *

Please list any members of your household who come to Lifetime EyeCare

Ethnicity *

Race *

Preferred Language *

Name of family doctor: *

Date of last exam

Medical History

Have you had any eye operations? *

Yes No

Please list the medications you take or bring a list to your exam (including oral contraceptives, aspirin, over the counter medications and home remedies) with dosage and frequency

If you have 5 or more please upload your list here.

Do you have any allergies to medications? *

Yes No

Select any of the following that you have or have had

Crossed / Lazy Eye Dry Eyes Cataracts Glaucoma Macular Degeneration Retinal Detachment Eye Infections Diabetic Eye Problems

Are you pregnant and / or nursing *

Yes No

Do you wear glasses? *

Yes No

Do you wear contact lenses? *

Yes No

Family History

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

All

YesNo

Blindness *

Yes No

Cataract *

Yes No

Crossed / Lazy Eyes *

Yes No

Glaucoma *

Yes No

Macular Degeneration *

Yes No

Retinal Detachment *

Yes No

Cancer *

Yes No

Diabetes *

Yes No

Thyroid Disease *

Yes No

High Blood Pressure *

Yes No

Other *

Yes No

Social History

Do you use tobacco products? *

Yes No

Do you consume alcohol? *

Yes No

Review of Systems

In the past year, have you been diagnosed or treated for the following health issues:

All

YesNo

CONSTITUTIONAL

Fever, Weight Loss / Gain *

Yes No

INTEGUMENTARY (Skin)

Yes No

NEUROLOGICAL

Headaches *

Yes No

Migraines *

Yes No

Seizures *

Yes No

EYES

Loss of Vision *

Yes No

Blurred Vision *

Yes No

Loss of Peripheral Vision *

Yes No

Double Vision *

Yes No

Mucous Discharge *

Yes No

Red Eyes *

Yes No

Itching *

Yes No

Glare / Halos / Sensitivity *

Yes No

Chronic Eye Infections *

Yes No

Flashes / Floaters *

Yes No

Computer Eye Strain *

Yes No

Dry Eyes *

Yes No

ENDOCRINE

Thyroid / Other Glands *

Yes No

EARS, NOSE, MOUTH, THROAT

Allergies / Hay Fever *

Yes No

Sinus Congestion *

Yes No

Dry Mouth / Throat *

Yes No

RESPIRATORY

Asthma *

Yes No

Emphysema *

Yes No

CARDIOVASCULAR

Diabetes *

Yes No

High Blood Pressure *

Yes No

Vascular Disease *

Yes No

GASTROINTESTINAL

Diarrhea *

Yes No

Constipation *

Yes No

GENITOURINARY

Genitals / Kidney / Bladder *

Yes No

BONES / JOINTS / MUSCLES

Rheumatoid Arthritis *

Yes No

Muscle / Joint Pain *

Yes No

LYMPHATIC

Anemia / Bleeding Problems *

Yes No

ALLERGIC / IMMUNOLOGIC

Allergic / Immunologic

Yes No

PSYCHIATRIC

Psychiatric

Yes No

INSURANCE / PAYMENT INFORMATION

Do you have vision insurance? *

Yes No

Copy of your vision insurance (Optional)

Do you have medical insurance? *

Yes No

Copy of your medical insurance (Optional)

MISCELLANEOUS

Whom may we thank for referring you?

FINANCIAL DISCLAIMERS

We will attempt to verify your insurance eligibility for services and/or materials before your appointment. Verification of eligibility is done as a courtesy only and is not a guarantee of payment. Please check with your plan administrator if you have any questions regarding your eligibility.

Initial *

LIABILITY

I understand Lifetime EyeCare will bill my vision and/or health insurance. I know that I am responsible for any remaining balance after the claim is submitted. Should my insurance not cover the services that are submitted in full, I agree to pay any outstanding balance.

In cases of divorce, the individual who receives the care is responsible for all charges. We will not bill a divorced spouse for the patient’s services. For minor patients, the responsible party bringing the minor patient to the clinic will be responsible for any co-pays or co-insurance at time of service.

Initial *

PRIVACY POLICY

In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for services, and to conduct health care operations involving our office. The Privacy Policy describes these uses and disclosures in detail.
I acknowledge that I have been offered and/or received a copy of the Privacy Policy from Lifetime EyeCare.

Initial *

AUTHORIZED ACCESS

If you'd like to authorize access to your medical records to any individuals please provide their name below.

I Authorize Access to My Medical Records to the following Individuals:

REFRACTION FEE

The part of your evaluation that determines your prescription is called a refraction. A refraction is also done under certain circumstances for diagnostic purposes. If you have routine vision benefits such as VSP or EyeMed, your refraction is typically included with your exam benefits. Medical insurances that do not include routine vision benefits, such as Medicare, do not cover a refraction. The fee for a refraction is $39. My signature below verifies I understand the refraction fee.

Initial *

RETINAL HEALTH SCREENING

The Optomap retinal health screening allows our doctors to provide the highest level of care and is mandatory for all new patients (age allowing). This screening enables us to detect retinal disease at an earlier state making it essential in the prevention and management of eye health for our patients. The fee for this screening is $39. Currently, there are few vision insurances which pay for this screening. Lifetime EyeCare will bill your vision insurance when applicable.

Initial *