File - Eye

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File - Eye
PATIENT INFORMATION
ACKNOWLEDGEMENT OF RECIEPT
OF PRIVACY PRACTICES
Mr. Mrs. Ms. Today’s Date: ___________
Signing this document signifies that you have
Name: _____________________________ M/F
received a copy of our
Address: _______________________________
Notice of Privacy Practices
*In the course of providing service to you, we
______________________________________
create, receive and store health information that
City: ___________________ State: _________
identifies you. It is often necessary to use and
Zip Code: _______________
disclose this health information in order to treat
Hm Phone: (
) ____________________
you, to obtain payment for our services, and to
Cell Phone: (
) ____________________
conduct healthcare operations involving our office.
The notice of Privacy Practices you have been
E-Mail:_____________________________
given describes these uses and disclosers in detail.
Birth Date: ______________
*When you sign this consent document, you
Social Sec#:______________
signify that you agree that we can and will use and
Employer: _______________________________ disclose your health information to treat you, to
Occupation: ______________________________ obtain payment for our services and to perform
Name of Spouse/Parent: ____________________ health care operations you can revoke this consent
How did you hear about us? Local Ppr/ Facebook in writing at any time. Unless we have already
treated you, sought payment for our services or
Website/ Online Search/Other ____________________________________
performed health care operations in reliance upon
OUR PAYMENT POLICY
our ability to use or disclose your health
information in accordance with this consent.
I acknowledge that I have received the Notice of
privacy practices from Dr.Melody O. Quenzer at
Eye Q Optometry.
1. Payment in full is due at time of services
2. A $30 service charge on all returned checks
3. Insurance Policy—Regardless of any insurance
coverage, the total balance due is the legal
X: ___________________________ Date________
If signing as a personal representative of the patient,
responsibility of the patient.
Payment not received within 60 days will be the describe the relationship to patient and the source of
authority to sign this form:
patients responsibility.
X: _______________________________________
4. I have read and understand the above:
I give permission to release my information to:
(Please Sign):_______________________________
_________________________________________
_________________________________________
INSURANCE INFORMATION
MEDICARE AUTHORIZATION
Who is responsible for the account?
_______________________________________
Relationship to Patient: ____________________
Medical Insurance Co: _____________________
Vision Ins. Co: ___________________________
Subscriber’s Name: ________________________
Subscriber’s DOB: ___________
Relationship to Patient: _____________________
I request that payment of authorized Medicare benefits be
made to me or on my behalf to Dr. Melody O. Quenzer
for any or all services.
To the extent permitted by law, I authorize any holder of
medical or other information about me to release to Dr.
Melody Quenzer any information needed to determine
these benefits for related services.
Signature of Beneficiary, Guardian/Representative
_______________________________Date:___________
Print name of Beneficiary/representative & Relationship:
Medical History
Last Eye Exam: ______________
Last Medical Exam: ___________
Do you have any allergies to medications? ____No ____Yes
If yes, explain: _________________________________________________________________
Please attach list of any medications you take including oral contraceptives, aspirin, over the
counter medications and home remedies: ____________________________________________
_____________________________________________________________________________
List all major injuries, surgeries and or hospitalizations you’ve had: _______________________
______________________________________________________________________________
List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent
eyes, glaucoma, retinal disease, cataracts, eye infections or eye injuries:____________________
_____________________________________________________________________________________________
Review of Systems: Do you currently, or have you ever had any problems in the following areas:
SYSTEM
YES NO ?
CONSTITUTIONAL
Fever, Weight loss/gain ____ ____ ____
INTEGUMENTARY (skin) ____ ____ ____
NEUROLOGICAL
Headaches
____ ____ ____
Migraines
____ ____ ____
Seizures
____ ____ ____
EYES
Loss of Vision
____ ____ ____
Blurred Vision
____ ____ ____
Distorted Vision/Halos ____ ____ ____
Loss of Side Vision
____ ____ ____
Double Vision
____ ____ ____
Dryness
____ ____ ____
Mucous Discharge
____ ____ ____
Redness
____ ____ ____
Sandy/gritty feeling
____ ____ ____
Itching
____ ____ ____
Burning
____ ____ ____
Foreign Body Sensation ____ ____ ____
Excess Tearing/Watering ____ ____ ____
Glare/Light Sensitive ____ ____ ____
Eye pain/Soreness
____ ____ ____
Chronic Eye/lid Infection ____ ____ ____
Sties/Chalazion
____ ____ ____
Flashes/Floaters
____ ____ ____
Tired Eyes
____ ____ ____
ENDOCRINE
Thyroid/Other Glands ____ ____ ____
SYSTEM
YES NO ?
EARS, 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
____ ____ ____
GENITOURINARY
Genitals/Kidney/Bladder ____ ____ ____
BONES/JOINTS/MUSCLES
Rheumatoid Arthritis ____ ____ ____
Muscle Pain
____ ____ ____
Joint Pain
____ ____ ____
LYMPHATIC/HEMTOLOGIC
Anemia
____ ____ ____
Bleeding Problems ____ ____ ____
ALLERGIC/IMMUNOLOGIC____ ____ ____
PSYCHIATRIC
____ ____ ____
If you answered YES to any of the above or have a condition not listed, please explain and list
medications:__________________________________________________________________________
____________________________________________________________________________________
Social History
This information is kept strictly confidential. However, you may discuss this portion directly with
your doctor if you prefer.
____ Yes I would prefer to discuss my social history information directly with my doctor.
Do you drive? ____No ____ Yes
If yes, do you have visual difficulty when you drive? ____No ____ Yes
If yes, describe: ____________________________________________________________
__________________________________________________________________________
Do you use tobacco products? ____No ____ Yes If yes, type/amount/how long:
________________________________________________________________
Do you drink alcohol? ____ No ____ Yes If yes, type/amount/how long:
________________________________________________________________
Do you use illegal drugs? ____No ____Yes if yes, type/amount/how long:
________________________________________________________________
Have you ever been exposed to or infected with: ____Gonorrhea ____ Hepatitis ____ HIV ____ Syphilis
Family History
DISEASE/CONDITION YES NO ?
RELATIONSHIP TO YOU
Blindness
____ ____ ____
____________________________________
Cataract
____ ____ ____
____________________________________
Crossed Eyes
____ ____ ____
____________________________________
Glaucoma
____ ____ ____
____________________________________
Macular Degeneration
____ ____ ____
____________________________________
Retinal Detachment
____ ____ ____
____________________________________
Arthritis
____ ____ ____
____________________________________
Cancer
____ ____ ____
____________________________________
Diabetes
____ ____ ____
____________________________________
Heart Disease
____ ____ ____
____________________________________
High Blood Pressure
____ ____ ____
____________________________________
Kidney Disease
____ ____ ____
____________________________________
Lupus
____ ____ ____
____________________________________
Thyroid Disease
____ ____ ____
____________________________________
Other: _______________ ____ ____ ____
____________________________________
and/or Disease
Doctor Signature: __________________________________ Date: __________________

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