Eye Su.rgery Associates

Eye Su.rgery Associates
Dlplomates, Arnerlc*n Board of Ophthalmology
2?.l0HoltyrtoodBlvrl. . Hollywood,ftoridg33020. g5+g2*2?1+ ltotlywood " 95,r"t62-TSg0Ft.Laqderdale ' 305940-27+0Miami' Fax95#923-8379
Memmtal West Medicat itldg. . 603 lL Flamirrgo lld- . Sulte 250 . Fembroke Plnet, Florlda 33028 ' 954",1t1'2777 ' fax 954-{lll-1$56
.I)an Msino Pediatric Center . X9S0 S. Commerc{: Fath*'oy ' West$n, Florltla 3333! ' 95+.595-2749
w'.eyesurg€ryassela(es.yo urnrd.coft r
DATE:
Pediatric Ophthalmology Strabismus - New Patient Questionnaire
Page 1: Background Information
CHILD'S NAME:
SEX:
F/M
SS#
DOB:
ADDRESS:
CITY:
ZIP:
STATE:
FATHER'S NAME:
DOB:
FATHER'S CELL#:
WRK#:
MOTHER'S NAME:
DOB:
MOTHER'S CELL#:
WRK#:
SS#:
HM#:
SS#:
HM#:
Family Status:
Family Physician (or Pediatrician)
n
Patient is living with parent
Living with relative, guardian, or foster parent
Address
Parents
Phone
Other Physicians(s) who should receive a report
(please give name, specialty, address, and phone):
n Married n
n
Yes
n
ruo
GRP #
CHILD /
FATHER /
MOTHER
GRP #
CHILD /
FATHER /
MOTHER
PARENT'S SIGNATURE:
pHY$lstANs net[A$€
I hereby authutrs paymsnt dir€{tly1o
irr$$rencs eompany olherwise payable lo dle,
Separated nDivorced
Name and ages of brothers and sisters:
Were you referred to us by your family physician/pediatrician?
lf "no", who referred you, or how did you hear of us?
INSURANCE INFORMATION :
PRIMARY
PLAN
'NSURANCE
INSURANCE ID #
WHO lS THE POLICY HOLDER:
SECO N D ARY'TVSURA N CE P LAN
INSURANCE ID #
WHO lS THE POLICY HOLDER:
are
ol benefils due tc me frorn my
. i furth*r
authodre ttre release ol any medical iniormation required by my insureece carsier{s}.
A {opy of lhis autharization may be used iri lid{t of lh6 otiginal.
I suthlrie€ eny holde,^ of ffsdicsl or ather hlonnaticn abfiBt rns to r€lea$e lo the Social
Se*urily Adfiini$tratiofi and Hoalth Care Frnancial &dmi*blraliorr or its ir\teri*€diariss $.
c*rrie* any infcrmatio$ ne*rle.d lor this cr R relaied ldedicare cla;m. I rsqussl o.9yfilefil of $sdical insuranen bsft€{ils either to myrelf cr {n the t}arly trho nsf,;eFts assignmsnt,
Iurvi*rs{andtlr&tisrrlftuianciaayrs$psnsibtctoctrsrqe$n$tes-'.ercdt}ylhisauthsrizatian.
PARENT'S SIGNATURE:
Pediatric Ophthalmology Strabismus - New Patient Questionnaire
Page 2: History Informatiort
Name:
Date:
Please check either yes or no for each of the following questions:
f*mity tlJsfory; Which af the patienfs relatives
Yes No
A
J
3
3
n
3
have had any o{ the foltowing?
Yes No
*n
J
ll
il
fl
n
fl
Blindness
Amblyopia {"lazy eye"i
Patching treatmefil
$lrabisrnus {"crossed eYed")
Eye muscle surgery
Glasses before age $
Are both parents alive and in good health?
Cataracts in childhood
Glaucoma in childhood
Other serious eye diseaso
Complications from anesthssia
Genetic disease {runs ln family}
Other serious illnesses:
*D
i3n
iln
fffl
n3
History af Eya Fr*blems: Has the patietlt had any af the following?
Yes
il0
cil
UA
Cl U
ll f
fl tr
Eye Fxam
Glasses
Patching
Recenf Sympfoms;
No
n n Crossed or wandering eyo
n n Excessive squinting
J il Double Vision
Cl 13 Excessive ey* rubbing
f3 l] Frequent tearing *r discharge
3 C Blurred vision
D n Light Sensitivity
Yes
Aga
Yes No
Age
No
How long?
Yes
€ye injury
fiye surgery
Other eye prcblems
How lang?
f"lo
n s
o a
u LJ
t3
t
fI
D
Frequent headaches
Tired eyes when reading
Weakness or nunrbness
Clurnsiness or bumping into things_
Can'? make normal evs contact
s n
Change in periormance in school or work
tl n
Other $ymptoms not mentfon*d above:
-
Other Medicat Prcbfems (Medical J'lisfory and freview of $ysfernsJ;
Yes
n
tr
A
tr
C
il
n
Yes
No
S
*
il
ill
il
n
A
n
il
il
J
S
il
S
f$o
i]
tr
fl
n
O
D
n
$kin rash
Neur*lngic prablerns
Mentalillness
Sickle ceil disease
Allergies to msdications {list:}
Otfrer allergi*s
Missing immunizations
Adhritis
Liat any previous surgery, hospital$zaticns, major iilnesses, or injuries {olher then eye problems);
Fever or weight loss
Fr*qu*nt 6ar infections
Other ear, nose or throat problems
Heart problems
Lung disease
Kidncy or urinary disease
List any rnedications the patient is taking, including eye drops:
Eirth llistary :
Eirth
weight:_
Yes
No {i{
* il
S .
il 3
lb, ,_
sz.
problem?}
Yes No {if "yes," why?}
what
was
the
}es,"
tl [l Selivered more than 2 weeks earty or late
Problems during pregnancy
Problems during delivery or foreeps delivery J n
Baby kept in hospitaldue to illnese
[] F Delayed development
Cesarean seclion
Heviewed by:
Dr.*