Patient Demographic Sheet
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- Merry Griffith
- 8 years ago
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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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DATE NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.0019 Joseph M. Phillips, M.D., Ph.D. Board Certified in Pain
More informationPlease fill out the new patient paperwork and bring it with you, along with a photo ID and health insurance or Medicare card.
Dear Patient, Thank you for choosing San Antonio Center for Physical Therapy for your rehabilitation needs. We want your time with us to be a positive experience, one that leads you down a road of successful
More informationMEDICATION LIST PATIENT NAME: DATE: Name of Medication Dosage (mg, microgram, etc.) How Many Times a Day
MEDICATION LIST PATIENT NAME: DATE: Name of Medication Dosage (mg, microgram, etc.) How Many Times a Day PATIENT REGISTRATION CONFIDENTIAL PLEASE COMPLETELY PRINT THE FOLLOWING AND SIGN BELOW PATIENT INFORMATION
More informationEye Diseases. 1995-2014, The Patient Education Institute, Inc. www.x-plain.com otf30101 Last reviewed: 05/21/2014 1
Eye Diseases Introduction Some eye problems are minor and fleeting. But some lead to a permanent loss of vision. There are many diseases that can affect the eyes. The symptoms of eye diseases vary widely,
More informationBody Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,
Medical History Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia
More informationPatient Demographics Sheet
Patient Demographics Sheet PLEASE PROVIDE YOUR PHARMACY INFORMATION BELOW: PREFERRED PHARMACY: PHARMACY LOCATION: PHARMACY PHONE NUMBER: FOR OFFICE USE ONLY Dr. Goldblatt Dr. Brown Last Name: First Name:
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Date: Body Technic Systems, Inc. 33790 Bainbridge Rd. Ste. 205 Solon, Ohio 44139 440-248-9255 phone 440-248-3608 fax Patient History Information Name: Date of birth: Address: City: State: Zip: Home phone:
More informationPATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Name: Date: Address: City/State: County: Zipcode: Home Phone: Work Phone: Cell Phone: E-MAIL ADDRESS: Date of Birth: Male Female Marital Status: Single Married Separated Divorced
More informationOrthopedic Initial Questionnaire
Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
More informationDear Patients and Prospective Patients:
www.cheverlychiropracticcare.com CheverlyChiroCare@yahoo.com Dr. Ella Pantazis 12200 Annapolis Rd #221 GlennDale MD 20769 301 464 5813 Fax: 301 464 5815 Dear Patients and Prospective Patients: Our office
More informationWelcome to Back Country Physical Therapy, Intake Form
Welcome to Back Country Physical Therapy, Intake Form Patient Information: Name: Social Security #: Sex (Circle): M / F Address: City: State: Zip: Home Phone: Birth date: Age: Marital Status (Circle):
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