Patient Demographic Sheet

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1 Patient Demographic Sheet Patient Name: Date of Birth: Address: City, State, Zip Code: Home Phone: Cell Phone: Work Phone: Sex: Male Female Marital Status: Married Single Other Occupation: Employer: In case of emergency, who may we contact? Name: Phone Number: IF PATIENT IS UNDER 18, PLEASE COMPLETE THE FOLLOWING Parent/Guardian Name: Relationship to Minor: Address: Phone Number: Employer: Date of Birth:

2 VISION AND/OR MEDICAL INSURANCE VISION INSURANCE Insurance Company: ID# Subscriber's Name: Subscriber's Date of Birth Relationship to Patient: VISION INSURANCE (if an additional vision plan exists) Insurance Company: ID# Subscriber's Name: Subscriber's Date of Birth Relationship to Patient: MEDICAL INSURANCE (PRIMARY) Insurance Company: ID# Subscriber's Name: Subscriber's Date of Birth Relationship to Patient: MEDICAL INSURANCE (SECONDARY) Insurance Company: ID# Subscriber's Name: Subscriber's Date of Birth Relationship to Patient: Assignment and Release: I certify that I, and/or my dependent(s) have insurance coverage with the above mentioned insurance(s) and assign directly to Leslie Reeves, O.D., Co. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. I agree that Leslie Reeves, O.D., Co. may use my health care information and may disclose such information to the above named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. _ Signature of Patient (Signature of Guardian if Patient under 18 years) Date

3 History Form What is the Reason for Today s Examination? (please check all that apply) Blurred Vision at Far Headaches Sunlight Sensitivity Blurred Vision at Near Eyestrain Eye Pain Needing new Glasses Poor Night Vision Floaters/Spots Needing new Contact Lenses Double Vision Dryness/Grittiness Burning Eyes Redness Other Itchy/Watering Eyes Patient Eye History When was your last vision examination? Doctor? Do You (please check all that apply) Wear Glasses? Wear Contact Lenses? Brand? Solution? Any Problems? Use a Computer? hours/day Spend Time Outdoors? hours/week Wear Prescription Sunglasses? Have more than one pair of current prescription glasses? Want information on Laser Vision Correction? Have you ever been diagnosed or treated for the following? Cataracts Eye Injury/Eye Surgery Retinal Detachment Corneal Abrasion Crossed Eye Corneal Disorder Eye infection Glaucoma Macular Degeneration Lazy Eye Iritis/Uveitis Other Dry Eyes Patient Medical History Family Physician Date of Last Physical Do you see any specialists? Physician: Specialty Physician: Specialty

4 Current Medications (Prescription or Over the Counter) (List Medications including eye drops, vitamins, and birth control pills) Allergies to Medications: No known Medical Allergies Yes: (please list) Have you ever been diagnosed with or treated for the following? Allergies High Cholesterol Heart Disease Cancer Diabetes Kidney Disease Rheumatoid Arthritis High Blood Pressure Thyroid Disorder Sexually Transmitted Disease Dementia/Alzheimer s Autoimmune Disease Asthma/COPD/Other Respiratory Disease Autism/ADHD/ or other Behavioral Disorder Other Social History: Do you drink? How much per week? Do you smoke? How much per week? Do you use alternative tobacco products (such as e-cigarettes or chewing tobacco)? Family History Has anyone in your family (blood relative) been diagnosed or treated for the following diseases? If yes, please list relation. Blindness Corneal Disease Glaucoma Heart Disease Corneal Disease Retinal Disorders Diabetes Macular Degeneration Lazy/Crossed Eyes High Blood Pressure

5 ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES The law requires that Leslie Reeves, O.D., Co. make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that: (PLEASE SELECT ONE BOX) I have read or had explained to me Leslie Reeves, O.D. Co. s Notice of Privacy Practice and agree to continue my care with Leslie Reeves, O.D., Co. under said terms. I was given the opportunity to read Leslie Reeves, O.D., Co. s Notice of Privacy Practices and declined but wish to continue my care with Leslie Reeves, O.D., Co. under the terms of Leslie Reeves, O.D., Co. s privacy policies. I have read or had explained to me Leslie Reeves, O.D., Co. s Notice of Privacy Practice and do not wish to continue my care with Leslie Reeves, O.D., Co. under said terms. The Notice of Privacy Practice could not be read due to the emergent nature of the care of other reason described as I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. Patient Date If you are signing as a personal representative of the patient, please indicate your relationship Representative Relationship to Patient

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