Scott R. Brizius, O.D. ● Stacey O. Embry, O.D. ● 2700 Lincoln Ave. ● Evansville, IN 47714 ● (812) 477-8696
Last Name_____________________________ First Name___________________
DATE:_______________
MI_______ Suffix _______
*The starred info is that which we are required by the government to obtain from you. Our office did not decide on these questions.*
Sex: M F Title: Dr. Mr. Ms. Mrs. Master Miss Rev.
Date of Birth___/___/_____
Address
*SSN:
City
State
Zip
-
*Primary Language:
*Country:
*Special Needs: Hearing impaired / Wheelchair / Translator / None
*Race:
How would you prefer to be contacted? (select below)
Home
-
*State of birth____
Work
Cell
US Mail
Email
Home Phone:
Work Phone:
Caucasian / African American / Asian /
Amer. Indian or Alaskan / Hawaiian or Islander / Other
*Ethnicity: (please select one option below)
Unknown
ext:
Not Hispanic or Latino
Occupation:
Employer:
Cell Phone:
*Mother’s Maiden Name:
Email:
Primary Care Doctor:
*Emergency Contact Name:
Hispanic or Latino
Phone Number:
Home
Cell
Relationship:
Insurance Information
Insurance Name: Vision______________________________ Medical_______________________________________
Account Responsible / Relationship to patient___________________________________________________________
Account Responsible Birth date ________/________/______ Social Security Number (Acct Resp.) ________________
Account Responsible address (If different from Patient’s)
Street ____________________________________ City ____________________ State ___________ Zip __________
Acknowledgement of Privacy Policy Receipt
I acknowledge that I was offered a copy of Dr. Scott R. Brizius’ and Dr. Stacey O. Embry’s Notice of Privacy Practices.
Printed Patient Name __________________________________________________________________________
Signature ________________________________________________________ Date _______/_______/_______
(Parent/Guardian Signature if patient is under 18 years of age)
Billing Agreement / Authorization
I authorize the office of Dr. Scott R. Brizius and Dr. Stacey O. Embry to bill my insurance and I fully understand that I am
responsible for the balance that is not covered by said insurance.
Should my balance become overdue and require the use of a collection agent, I authorize the office to contact me by any
telephone number I provide to you, email, text message, or postal mail regarding my account.
Some insurance companies (Anthem included) have contractual charges that they see as not necessary. Should my insurance
deem certain charges not necessary or covered for whatever reason, I agree to pay those charges in full.
Printed Patient Name __________________________________________________________________________
Signature ________________________________________________________ Date _______/_______/_______
(Parent/Guardian Signature if patient is under 18 years of age)
*This information is that which we are required by the government to obtain from you.
Continued on back side of page 
Name _________________________________
Date ______/_____/_______
Are you having any trouble with your eyes? ____________________________________________________________
Do you wear glasses? Y/N
Do you wear Contact Lenses? Y/N - if yes, RGP or soft contacts? ______________
Do you use a computer on a daily basis? Y/N If so, how many hours per day? ________________
*General Health
Do you have problems with any of these systems? (Please circle yes or no and use space provided if necessary.)
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Cardiovascular____________________________ Y/N Skin Disease___________________________________
Ears, Nose, Mouth, Throat___________________ Y/N Neurological___________________________________
Respiratory_______________________________ Y/N Psychiatric_____________________________________
G.I._____________________________________ Y/N Endocrine / Gland_______________________________
Genitourinary_____________________________ Y/N Blood / Lymphatic______________________________
Bones / Muscles___________________________ Y/N Immune Disease________________________________
Other:___________________________________ Female Patients: are you Pregnant and/or Nursing? ________
Diabetes: Type_______ Approx. Date of diagnosis_____________________________
Surgical History (eye surgeries, AND any major surgery i.e. back, brain, reproductive)
Approx. Date of Surgery_________________________
If it was related to the eyes circle: Right or Left
Procedure_______________________________________ Surgeon_________________________________________
Approx. Date of Surgery_________________________
If it was related to the eyes circle: Right or Left
Procedure_______________________________________ Surgeon_________________________________________
Past / Present / Family / Social History
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Self Past/Present Eye History
Date Diagnosed
Glaucoma
_____________
Cataracts
_____________
Macular Degeneration _____________
Eye Injury
_____________
Retinal Disease
_____________
Other Disease________ _____________
Blindness
_____________
Crossed Eyes
_____________
Lazy Eye
_____________
Diabetes
_____________
Dry Eye
_____________
Refractive
_____________
Other_____________
_____________
Other_____________
_____________
Family History / Relationship
(include which side of family w/relationship)
(For example: Maternal Grandmother or MGM)
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Glaucoma _________________
Cataracts__________________
Macular Degeneration_______
Eye Injury________________
Retinal Disease____________
Other Eye Disease___________
Blindness_________________
Crossed Eyes______________
Lazy Eye_________________
Diabetes__________________
Cancer___________________
Heart Disease______________
Other____________________
Other____________________
*Social History
Frequency
*Tobacco
Current______
Former _____
Never _____
Y/N * Drug Use ___________
Y/N * Alcohol
___________
Occupation __________________
Hobbies _____________________
_____________________
Other _____________________
Past/Present Medical History
Condition___________________
Details_____________________
Medications
Primary Care Physician ____________________________________________________________________________
Current Medications (including any eye related medications) _______________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Any Allergies to Medications? Yes No If Yes, please list:_______________________________________________
*This information is that which we are required by the government to obtain from you.