Welcome to Underwood Optical
www.underwoodoptical.com
Patient Name:__________________________________________________________________________Date of Birth:____ /____ /____
Address:_________________________________________City:_________________________________State____________Zip________
Telephone Number (Home)_____________________(Cell)_________________________(Work)_______________________________
Email Address ______________________________________________________________________________________________________
Social Security Number_____________________________________Occupation/Employer_________________________________
Sex:___ Female___ Marital Status:____________ Emergency Contact #_______________________________________________
Spouse or Parent
Race: __________________________ Ethnicity: Hispanic or Latino or Not Hispanic or Latino
Name of Primary Doctor/Clinic:_________________________________________Date of last medical exam:____ / ____ /____
Please indicate your method of payment: Cash___ Check___ Credit Card___ Insurance___
PLEASE PRESENT ALL INSURANCE CARDS AND IDENIFICATION AT DESK
I consent to treatment as necessary or desirable to the care of the patient named above, including but not limited to medications or other studies
that may be used by the attending optometrist, or qualified designate. Charges shown by statements are agreed to be correct and reasonable unless
protested in writing within 30 days of billing date. In the event legal action should become necessary to collect an unpaid debt for optical services
rendered to me or my family, I/we agree to pay reasonable attorney’s fees or other such cost as the court demes proper. I hereby authorize
payment of medical insurance to Dr. Underwood, and authorize release of any medical information acquired in the course of my examination of
treatment.0
SIGNATURE:_______________________________________________________________Who is responsible for this bill?________________________________
Smoking Status: Never___ Former___ Current___
Alcohol: None___ Occasional___ Social___
Major Injuries/Surgeries
:_______________________________________________________________________________________________________________________
Other Medical History:
____________________________________________________________________________________________________________________________
Have you ever had any eye injuries? Yes / No Describe: ________________________________________________________________________________
Have you ever had any eye surgeries? Yes / No Describe: _______________________________________________________________________________
Do you use any eye medication? Yes / No Describe: ____________________________________________________________________________________
What is the date of your last Eye Exam?__________________________________________________________
Have you ever been diagnosed with any of the following?
Cataracts: Yes / No
Glaucoma: Yes / No
Macular Degeneration: Yes/ No
Retinal Detachment: Yes / No
Crossed or Lazy Eye: Yes / No
Eye turn strabismus: Yes / No
What is your primary vision concern today?
_________________________________________________________________________________________________
R. Duke Underwood, OD & Underwood Optical Inc. Reserves the right to modify the privacy practices outlined in the notice. I acknowledge that I
received a copy of R. Duke Underwood, OD & Underwood Optical, Inc. Notice of Privacy Practices.
Patient Name: ________________________________________________________________________________________________________________________
Signature:_____________________________________________________________________________________________________________________________
Signature of Patient Representative:
_______________________________________________________Date:____________________________________________
(Required if the patient is a minor or an adult who is unable to sign the form)
***PLEASE TURN OVER AND COMPLETE THE OTHER SIDE***
Personal Medical History: Please check if any of the following applies to you past or present and list all medication taken below. If you have none
of these conditions please check NONE.
Cardiovascular:
Constitutional:
Psychiatric:
___High Blood Pressure
___Heart Disease
___Vascular Disease
___Stroke
___Cancer
___Other:_________________________
___None
Neurological:
___Cancer:____________________
___Fatigue Syndrome
___Developmental Disability
___Other:_____________________
___None
___ADHD
___Depression
___Schizophrenia
___Anxiety
___Bipolar Disorder
___None
Musculoskeletal:
Integumentary:
___Multiple Sclerosis
___Epilepsy / Seizure
___Cerebral Palsy
___Tumor
___Migraines
___Other:_________________________
___None
___Arthritis
___Fibromyalgia
___Muscular Dystrophy
___Osteoarthritis
___Osteoporosis
___Other:_____________________
___None
___Eczema
___Rosacea
___Shingles
___Psoriasis
___Other: ________________________
___None
Hematological:
Gastrointestinal:
Ear/Nose/Throat:
___Anemia
___Leukemia
___Ulcer
___Hypercholesterolemia
___Other:_________________________
___None
Endocrine:
___Cohn’s Disease
___Colitis
___Ulcer
___Acid Reflux
___Other:_____________________
___None
Respiratory:
___Hearing Loss
___Sinusitis
___Dry Mouth
___Other:________________________
___None
___Type 2 Diabetes
___Type 1 Diabetes
___Thyroid Problem
___Hormonal Dysfunction
___Other:_________________________
___None
___Asthma
___Bronchitis
___Emphysema
___COPD
___Sleep Apnea
___Other:______________________
___None
Medication Allergies: (Please List)
None_____
Environmental Allergies:
Please list any medications you are currently taking or ask our staff to make a copy of tour medication list. Include all medications, vitamins,
herbs, supplements, and over the counter medications.
1.___________________________________
2.___________________________________
3.___________________________________
4.___________________________________
5.___________________________________
6.____________________________________
7.____________________________________
8.____________________________________
9.____________________________________
10.____________________________________
Family History: Has anyone in your immediate family (grandparents, parents, siblings and children) been diagnoses with:
Disease/Condition
Lupus Yes/No
High Blood Pressure Yes/No
Diabetes Yes/No
Heart Disease Yes/No
Thyroid Disease Yes/No
Cancer Yes/No
Relationship
______________
______________
______________
______________
______________
______________
Blindness Yes/No
Cataracts
Yes/No
Glaucoma
Yes/No
Crossed Eyes Yes/No
Macular Degeneration
Retinal Detachment
Relationship
______________
______________
______________
______________
Yes/No ______________
Yes/No ______________