E ye to E ye
PROBLEM-ORIENTED FORM
PATIENT INFORMATION
Are you a new patient? □ yes □ no
Date: __________________
Patient: ______________________________________________________________________________________________________________
First
MI
Last
Address: _____________________________________________________________________________________________________________
City
Gender: □ M
□ Single
□ F
□ Married
State
Zip Code
Age ____________ Birth date: _______________ Patient SSN: _______________________________________________
□ Partnered
□ Other: _____________________ Employee status: □ Full
□ Part
□ Unemployed □ Student □ Retired
Employer: _________________________________________________ Occupation: _________________________________________________
How were you referred to our clinic? _____________________________ Hobbies/Interests: _____________________________________________
INSURANCE
Health Insurance Carrier: _______________________________ Member ID: _____________________________ Group#:____________________
Who is the Primary member? ________________________________ Their birth date: _____________ Their SSN:__________________________
Relationship to patient: _____________________________________
CONTACT INFORMATION
What is the best method of communication for you? Please check any or all. □ Phone □ Email □ Text □ Facebook
Home ______________________________ Work ____________________________ ext. _______ Mobile:________________________________
Email address: __________________________________________________________________________________________________________
EMERGENCY CONTACT Name: __________________________________ Relationship:________________ Number: ______________________
POLICIES
My signature indicates:
1. I have been informed of my rights under the HIPAA Privacy Policies.
2. I hereby authorize the doctor to release all information necessary to secure the payment of benefits
3. I authorize the use of this signature on all insurance submissions.
4. As a potential contact lens (CL) wearer, I have read and understood the CL Guide and CL professional fees, and I have been informed that
potential risks do exist in wearing CL.
5. I understand that all fees paid for professional services are non-refundable and are payable at the time of service.
6. I accept the policies regarding the purchases of spectacle lenses, frames, or contact lenses are non-refundable.
7. I understand that I have full financial responsibility for all charges whether or not paid by my insurance(s).
8. I understand that I will be billed whichever is appropriate based on the diagnosis from my exam and will be advised in difference of co-pay.
Signature: ________________________________________________________________ Date: ______________________________________
Or Legal Guardian (if patient is under 18):
OFFICE USE ONLY – DIAGNOSIS CODES
PLEASE CONTINUE TO THE BACK
E ye to E ye
PROBLEM-ORIENTED FORM
HOW CAN WE HELP YOU TODAY? / CHIEF COMPLAINT
Briefly indicate any signs and symptoms you are experiencing.
□
Eye injury from: ________________
□
Headaches
□
Foreign body sensation
□
Red eyes
□
Eyelids swollen
□
Light sensitivity
Eyelids crusty or stick together
Eyes itch
□
□
□
Blurred vision
Watery eyes
□
Mucous or filmy discharge
□
Double vision
Eyes burn
□
Bump on lid
□
Halos
Pain
Eyes feel dry / sandy / gritty feeling
Which eye?
□ Right
□ Left
When did this first occur?
□
□
Flashes / Floaters
□ Both
□ This morning upon awakening
□ Today
□ This afternoon □ Last night
□ Other: _________________________
Briefly tell us what happened or any additional signs and symptoms are you are experiencing.
_____________________________________________________________________________________________________________________
EYE HEALTH / SOCIAL HISTORY
Last eye exam: ______________ Last physical exam: ______________
Do you wear glasses?
□ Yes □ No
□ All the time □ Occasionally
□ Driving □ Reading
Do you wear contacts? □ Yes □ No
□ Computer
Are you wearing contacts at this moment? □ Yes □ No
□ All the time □ Occasionally
Have you had any eye injuries in the past?
Have you had any eye surgeries in the past?
Do you smoke?
□ No
Are you pregnant? □ No
□ Yes □ No
If yes, explain: __________________________________________________________
□ Yes □ No
If yes, explain: ________________________________________________________
□ Yes, ____ packs a day
□ Yes, _____ months
REVIEW OF SYSTEMS
Self Family
EYES:
Self
NEUROLOGICAL:
EARS / NOSE / THROAT:
Glaucoma
□
□
Stroke
Chronic cough
Macular degeneration
□
□
Headaches
Sinuses
Cataracts
Retinal detachment
Retinal disease
□
□
□
□
CARDIAC:
Heart disease
Migraines
□
□
Dry mouth
Seizures
□
□
PSYCHIATRIC:
ENDOCRINE:
□
□
High blood pressure
Kidney problems
□
□
□
□
Thyroid disease
RESPIRATORY:
□
□
MUSCULOSKELETAL:
Asthma
□
□
Arthritis
□
□
Anemia
MEDICATIONS
□
Depression
□
□
Anxiety
□
□
□
□
□
□
Cancer
Type:_______________
□
□
HEMATOLOGIC:
Bronchitis
□
OTHER:
Diabetes
Chest pain
Emphysema
Family
Self Family
HIV
HEPATITIS
□
□
ALLERGIES
List medications you are currently taking, including eye drops:
List all of your allergies, including to certain medications:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________