Patient History Form Thank you for choosing us for your eye care needs. We are delighted to have you as a patient and appreciate the confidence you placed in us. Please take a moment to complete the following Information. Any Information we already have on file will appear on this form. Please review all completed areas to ensure that the information we have is current and accurate, If you have any questions, please do not hesitate to ask. Step 1 of 4 - Patient History 25% Personal InformationsName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Patient's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth Date Format: MM slash DD slash YYYY Social Security NumberPrimary PhoneMake your selectionHomeMobileDay/Work PhoneMobile PhoneEmergency PhoneEmergency ContactEmail Person Responsible for this A/C First Last Patient HeightPatient WeightAuthorized Person to Discuss Health Info First Last Relationship to PatientSexMake your selectionFemaleMaleStatusMake your selectionSingleMarriedOtherEmployment StatusMake your selectionFull Time StudentPart Time StudentEmployedOtherSexual OrientationMake your selectionStraight/HeterosexualGay/Lesbian/HomosexualBisexualOtherUnknownDeclined to SpecifyGender IdentityMake your selectionIdentifies as MaleIdentifies as FemaleTransgender Male ( Female to Male )Transgender Female ( Male to Female )Neither/GenderqueerAdditional/Other GenderDeclined to SpecifyRace & EthnicityMake your selectionAmerican Indian or Alaska NativeAsianBlack or African AmericanDeclined To SpecifyHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteOther RaceNot Hispanic or LatinoPreferred LanguageMake your selectionEnglishSpanish/CastilianChineseJapaneseVietnameseKoreanGermanFrenchDeclined To Specify InsurancesPlease bring all insurance cards with you to your appointment.Primary InsuranceInsurance Company NameInsured's Name First Last Insured's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Insured's ID NoGroup NoSexMake your selectionFemaleMaleInsured's Date of Birth Date Format: MM slash DD slash YYYY Patient Relationship to InsuredSelfSpouseChildOtherDo you have secondary insurance?NoYesInsurance Company NameInsured's Name First Last Insured's Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Insured's ID NoGroup NoSexMake your selectionFemaleMaleInsured's Date of Birth Date Format: MM slash DD slash YYYY Patient Relationship to InsuredSelfSpouseChildOtherHow did you find our office? (Specify one) Web Search Social Media Phone Book Insurance Listing Drive By Other Patient Doctor Patient NameDoctor NamePlease Read: In order to control the cost of billing, we ask that the patient's portion is paid at the time services are rendered unless other arrangements are made in advance. We would rather control billing costs than be forced to raise our fees. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance. Accounts 90 days old are subject to collection fees. There will be a service charge on all returned checks. Payment from my insurance is to be paid directly to Ultimate Eyecare Santa Fe, LLC. I understand that Medicare Novitas-Part B will be billed as my primary insurance. I underetand that billing antsecondary insurance is my responsibility. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made when the claim is processed. SignatureDate Date Format: MM slash DD slash YYYY Patient History and InformationReffering Physician M.D. P.A. N.P. R.N. A.B.O. O.D. O.D., F.A.A.O. Name First Last Clinic NameClinic PhoneClinic Address City State / Province / Region ZIP / Postal Code Health HistoryReason for today's exam?When was your last eye exam?When was your last health exam?Past illinesses and injuriesPast surgeriesCurrent eye dropsCurrent medicationsReactions, sensitivities medicinesSpecific allergiesCurrent Eye SymptomsPlease check off any current conditions you suffer from Glare Sensitivity Headaches Light Sensitivity Tired Eyes Buring Dryness Excess Tearing/Watering Eyelid Swelling Eye Pain or Soreness Foreign Body Sensation Infection of Eye or Lid Itching Mucous Discharge Drooping Eyelid Redness Sandy or Gritty Feeling Blurred Vision Distance Blurred Vision Near Distorted Vision (Halos) Double Vision Flashes Floaters or Spots Fluctuating Vision Loss of Central Vision Loss of Side Vision Loss Of Vision Other Please check off all medical conditions you have ever had Amblyopla (Lazy Eye) Infection of Eye or Lid Blindness Cataract Color Blindness Diabetic Retinopathy Dry Eye Syndrome Eye Injuries Glaucoma Glaucoma Suspect High-Risk Medication Macular Degeneration PVD (Vitreous Detachment) Retinal Detachment Crossed Eyes Keratoconus Corneal Disease Other Please check off your current health conditions you have Fever, Weight Loss, Fatigue, etc Ears, Nose, Throat Cardiovascular (High BP etc.) Respiratory (Asthma) Gastrointestinal Kidney, Bladder Muscles, Bones, Joints Skin (Rash, Itching, etc) Neurological (Multiple Sclerosis) Anxiety or Depression Thyroid, Diabetes Blood (Cholesterol, Anemia, etc) Allergic, Immune Pregnant Nursing Medical History QuestionnairePlease check off the following conditions that run in your family Amblyopia (Lazy Eye) Blindness Cataract(s) Color Blindness Eye Tumors Glaucoma Glaucoma Suspect Macular Degeneration Retinal Detachment Strabismus (Eye Turn) Arthritis Cancer Diabetes Heart Disease High Blood Pressure Kidney Disease Lupus Stroke Thyroid Disease Others Do you drink alcohol? No Occasional 1 Per Day 2-3 Per Day 4+ Per Day Smoking Status Non-Tobacco User Current Tobacco User Light Tobacco User Moderate Tobacco User Heavy Tobacco User Unknown/Not Indicated Tobacco use cessation intervention, counselling? Yes No Tobacco use cessation pharmacologic therapy? Yes No Do you use illegal drugs? Yes No Do you engage in regular exercise? Yes No Do you use nutritional supplements? Yes No Current occupationInfluenza immunization? Recommended Administered Hobbies, Interests?Spectacle Lens HistoryDo you use computer? Yes No How many hours in a day?Distance from computer?Do you drive? Yes No Mileage to work each way?Do you have glare problem? Yes No Visual difficulty when driving? Yes No Problems with night vision? Yes No Do you wear currently glasses? Yes No Since?Type of glasses? Full Time Part Time Distance Close Glasses owned? Single Vision Bifocals Trifocals Backup Safety Sports Progressive Trouble in the past with glasses? Yes No Do you wear sunglasses? Yes No Are your sunglasses your current prescription? Yes No Special Eyewear Needs Computer (special prescriptions, special anti-glare tints or coatings) Safety glasses (gardening, woodworking, welding) Occupational (mechanics, plumbers, pilots) Sports/Hobbies (racquet sports, motorcycle) Contact Lens HistoryIf not a contact lens wearer, are you interested in trying contact lense at this time? Yes No Have you ever tried to wear contact lenses? Yes No Reison for stopping?Do you currently wear contact lenses? Yes No Since?Type and brand of contact lenses?How many days in a week?How many hours in a day?Today's wearing time?Please rate the following on a scale of 1-10, with 1 being POOR to 10 being EXELLENCELens Confort - Left Eye12345678910Lens Confort - Right Eye12345678910Distance Vision - Left Eye12345678910Distance Vision - Right Eye12345678910Near Vision - Left Eye12345678910Near Vision - Right Eye12345678910What solutions do you use? Cleaner Disinfectant Enzyme
Saturday: Optical Shop hours from 9-12 by appointment only.