Eger Eye Group, P.C.

Transcription

1 Eger Eye Group, P.C. Last Name: Middle Initial: First Name: Birth Date: Street Address: City/State/Zip: Home Phone: ( ) Work Phone: ( ) Occupation: Employer: Soc. Sec. #: Age: Sex: M F Race: Accompanied By: Relationship: In case of emergency please contact: Phone: ( ) Height: Weight: Primary Care Physician: Last Eye Exam: Last PCP Visit: Reason for last visit to PCP (circle one): Wellness Disease Other Reason for Today s Visit(Circle): Blurry Vision Itching Redness Glare Mattering Headaches Other: REVIEW OF SYSTEMS (please circle all pertinent) Constitutional: None Fatigue Lightheaded Weakness Muscle Cramps Weight Loss/Gain Loss of Sensation Cardiovascular: None High Blood Pressure Heart Disease High Cholesterol Angina Carotid Artery Disease Ear/Nose/Throat/Mouth: None Sinusitis Ringing in Ears Dizziness Vertigo Chronic Strep Dermatitis TMJ Respiratory: None Asthma COPD Pulmonary Embolism Sleep Apnea Wheezing Sarcoidosis Pneumonia Gastrointestinal: None Celiac Constipation Crohn s Disease Acid Reflux Irritable Bowel Ulcers Cancer Genitourinary: None Prostatic Hyperplasia Bladder Infection Dialysis Incontinence Menopause Endometriosis Musculoskeletal: None Arthritis Gout Back Pain MS Cramping Lupus Tendonitis Joint Pain Fibromyalgia Integumentary: None Acne Alopecia Skin Color Changes Rosacea Skin Cancer Vitiligo Easy Bruising Lice Neurological: None Alzheimer s Bell s Palsy Dementia Headaches Migraines MS Parkinson s Stroke Vertigo Psychiatric: None ADD ADHD Depression Anxiety Confusion Panic Attacks Schizophrenia Bipolar Endocrine: None Diabetes (Insulin Non-insulin) High Cholesterol Thyroid (Hyper Hypo) Osteoporosis Hematologic/Lymphatic: None Anemia Leukemia Lymphoma (Hodgkin s Non Hodgkin s) Sickle Cell Lupus Allergic/Immunologic: None Seasonal Autoimmune Disease Drug Allergies Food Allergies Other (please explain): Diabetics Only: Last Fasting Blood Sugar: Last HbA1C: Next PCP Visit:

2 PAST PERSONAL HISTORY Please list all surgeries and the date of surgery: Please list all medications you take including dosage (you may provide a list): Allergies (drug and environmental): Do you have (circle): Glaucoma Cataracts Macular Degeneration Eye Injury Retinal Disease Other Disease BlindnessEye Turn Lazy Eye Diabetes Dry Eye Blurred Vision Glasses Headaches Flashes Floaters Double Vision Redness Itching Burning Tearing Tired Eyes Eyelid Droop Do you wear glasses? Y N Bifocal? Y N Do you wear contact lenses? Y N What kind? FAMILY HISTORY (please circle all that apply and list who next to it): Glaucoma: Cataracts: Macular Degeneration: Wet Dry Eye Injury: Retinal Disease: Other Disease: Diabetes: Blindness (include reason): Strabismus: Amblyopia: Cancer (include type): Heart Disease: High Cholesterol: High Blood Pressure: Stroke: Other (please explain): SOCIAL HISTORY (please circle all that apply): Have you ever used tobacco? Y N If yes: How long? Type of tobacco used: How many packs per day? Quit when? Do you use narcotics? Y N If yes: What type? Frequency of use: Do you drink alcohol? Y N If yes: Social only OR-- drinks per week Do you drink caffeine? Y N If yes: cups per day The Eger Eye Group PC requests permission to contact you via mobile phone and/or for appointment confirmation and promotional opportunities. Please provide your information below to authorize consent. Mobile phone Primary address Patient or Parental Signature: Date: Re-attestation: Date: Date: Date: Date: Reviewed by Doctor s Signature: Date:

3 Authorizations Important, please read the following as there has been a significant change made by most insurance companies EFFECTIVE: January 1, 2012 We often have patients that have both vision and medical insurance. They are very different in terms of the services they cover and it s important for our patients to understand those differences. Vision coverage is mainly designed to determine a prescription for eyeglasses (called a refraction), and to evaluate the health of their eyes. It is not designed or equipped to deal with medical conditions, diagnoses, and/or treatment plans. When a medical diagnosis or condition is present (such as high blood pressure, diabetes, or an eye disease such as infections, dry eyes, allergy, cataracts, macular degeneration, to name just a few) it is necessary to file the claim for your visit with your major medical carrier and the co-pays for that insurance will apply as well as any non-covered service (like a refraction). Vision insurance does not cover medical eye problems, just as medical insurance does not cover routine vision problems. Our office does not make these rules; they are defined by the insurance carriers themselves. There may be no way to know prior to the examination (especially if you are new to our office) which type of insurance will apply or with whom our office will be able to file a claim on your behalf. We make every effort to be a provider for most major carriers for your convenience and we will file those claims for you when there is a medical problem. In the event that we do not take your major medical/vision insurance, we will provide you with an itemized receipt so that you may file with your carrier for reimbursement. If you have any questions, or would like a copy of this authorization statement, please let us know. I understand the paragraph above and authorize The Eger Eye Group to file a claim with my insurance. Printed Name Signature Date Federal law, Medicare and most health insurances mandate that the following information be accurately completed. Please answer all appropriate questions. Commercial Insurance and Medicare Authorization Name of Insurance Holder: Please present your insurance card(s) so a copy may be placed in your record. Vision Plan: ID# I request that payment of authorized commercial insurance and/or Medicare benefits be made on my behalf to the doctors of the Eger Eye Group for any services provided me by that physician. I authorize the release of any medical information about me to the insurance carrier or the Centers for Medicare and Medicaid Services and its agency to determine these benefits or the benefits payable for related services. I understand that I am financially responsible to said physician for any balance not covered by my insurance carrier at the time of service. I understand that any delinquent payments as determined by this office are subject to collection and civil prosecution by magisterial decree. Patient Signature: Date:

4 Welcome! You are here because you care about your vision and we're here because we care too! Please fill out this brief questionnaire so that we can better help you to protect that vision as well as care for the overall health of your eyes. Name Date Please circle how often you currently wear the following forms of sight correction and/or sight protection Contact Lenses Always Often Rarely Never Eyeglasses Always Often Rarely Never Plano Sunglasses (Non-prescription) Always Often Rarely Never Prescription Sunglasses Always Often Rarely Never Your eyewear is a part of your life! It should function perfectly, look great and always feel completely comfortable! Do you have any of the following problems with your current eyewear? Please check all that apply. Too heavy (They leave marks on nose or cheeks.) Poor fit (They slip down or are uneven.) Squeeze too hard on the temples Wrong size (too large or too small) Difficulty with bifocal Too much glare Irritating under fluorescent lights Inadequate amount of reading area in the lenses Need constant adjustment Outdated, faded or worn out Screws fall out too easily Other, please comment:

5 Please tell us what you do! Just circle your participation level in the following activities and indicate whether or not you currently have eyewear specific for that activity. At Home / Work: I have eyewear for this activity Reading Frequently Infrequently Never Yes No Computer Frequently Infrequently Never Yes No Television Frequently Infrequently Never Yes No Other (musical instruments, hobbies, etc.): Frequently Infrequently Never Yes No Outside: Driving Frequently Infrequently Never Yes No Cycling Frequently Infrequently Never Yes No Walking/Jogging Frequently Infrequently Never Yes No Golf Frequently Infrequently Never Yes No Tennis Frequently Infrequently Never Yes No Water Sports Frequently Infrequently Never Yes No Snow Sports Frequently Infrequently Never Yes No Other: Frequently Infrequently Never Yes No Do you have any other special visual needs? If so, please describe: