AUSTIN RETINA ASSOCIATES PATIENT INFORMATION

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1 AUSTIN RETINA ASSOCIATES PATIENT INFORMATION NAME: MAILING ADDRESS or NURSING HOME NAME & ADDRESS: Last First Middle Initial CITY: STATE: ZIP CODE: - TELEPHONE: HOME:( ) CELL: ( ) WORK:( ) DATE OF BIRTH: / / AGE: RACE: MARITAL STATUS: SINGLE MARRIED DIVORCED WIDOWED GENDER: MALE FEMALE DRIVERS LICENSE # STATE: SS#: 9 digit EMPLOYER: OCCUPATION: PARENT/EMERGENCY CONTACT: PHONE: ( ) CELL: ( ) MEDICARE #: MEDICAID #: HEALTH INSURANCE NAME: INSURED DATE OF INSURED INSURED NAME: BIRTH: / INSURED / DATE OF BIRTH: SS#: / / INSURED ID#: GROUP #: RELATIONSHIP TO PATIENT: OTHER HEALTH INSURANCE NAME: INSURED DATE OF INSURED INSURED NAME: BIRTH: / INSURED / DATE OF BIRTH: SS#: / / INSURED ID#: GROUP #: RELATIONSHIP TO PATIENT: REFERRING PHYSICIAN NAME: (first) (last) PRIMARY CARE PHYSICIAN NAME: (first) (last) I authorize any and all insurance benefits, to which I am entitled for services rendered by Austin Retina Associates, to be paid directly to Austin Retina Asscociates. I agree it is my responsibility to pay charges not covered by my insurance. I authorize any holder of medical or other information about me to release to the Social Security Administration, HCFA, and its subsidiaries, and other insurance carriers or health care providers, any information needed for this or a related Medicare or other insurance claim. I permit a copy of this authorization to be used in place of the original. This authorization is in effect until I choose to revoke it. SIGNATURE: DATE: / / PATIENT INFORMATION xls

2 Name: Age: Medical History: Please check all that apply. Vision Problems headaches side vision loss pain blank spots night vision loss curtain flashes blurring haze floaters double vision distortion spots sudden loss Trauma: : Eye Surgeries None Cataract/Implant Glaucoma Laser Retina : Illnesses and Conditions: None High Blood Pressure Arthritis Kidney Disease Heart Attack When: Vascular Disease Stroke When: HIV Cancer Type: Heart Disease Diabetes How Long: Asthma : Surgeries None Appendix Gallbladder Hysterectomy Heart..type? Prostate Cancer type? : Social History Drink alcohol Smoke in the past Smoke now Use street drugs : Allergies None Penicillin Iodine Codeine Shell Fish Sulfa : Family History None Diabetes Glaucoma Cataract : Please list medications including nonprescription drugs: Signature: Date: medical information ARA.xls

3 Review of Systems NAME DATE 1) Constitutional Fever Weight loss 2) Eyes Blurred vision Discharge Double vision Pain 3) Ears, Nose, Mouth, Throat Pain Hearing loss Mass Smell Discharge 4) Cardiovascular Chest pain SOB on exertion Irregular heart beat 5) Respiratory Short of breath Asthma Cough 6) Gastrointestinal Bowel habits/change Stomach pain Diarrhea Ulcers Constipation 7) Hematologic /Lymphatic Anemia Blood disease Free bleeder Swollen lymph nodes 8) Musculoskeletal Weakness Joint pain Decreased ROM 9) Integument (Skin/Breast) Masses Rash Tumors Pigmented lesions 10) Neurologic Weakness Numbness Tingling Patient Signature

4 Austin Retina Associates Written Acknowledgement Form Our Notice of Privacy Practice provides information about how we may use and disclose medical information about you. As provided in our notice, the terms of our notice may change. If we change our notice, lou rnay request a revised copyf (P1ease prinr patient name) have been provided a copy of Austin Retina's Notice of Health Information Practices. I have had an opportunity to read the Notice of Health Information Practice s. I understand that I may ask questions of the Privacy Officer if I do not understand any information contained in the Notice of Health Information Practices. Patient Signature Date Autho nzed Representative of Patient R.elationship to Patient

5 Austin Retina Associates Autho rtzatton to R.elease Medical Information authorrze Austin Retina Associates to release all medical information including test results and future appointment dates and/or tirnes to the following friends or relatives: (please print) Please check all that apply where we may leave a message for you. Your answering machine At your place of employment May we send you a postcard regarding appointments? Yes It[o Patient/Guardian S ignature Date

Patient Information. Name: Soc Security #: Date of Birth: Age: Male / Female. LOCAL Address: Street City State Zip. Phone: Home: Cell / Work:

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