Medical History Questionnaire
Appointment Date: Click here to enter text.
Primary Insurance: Click here to enter text.
Secondary Insurance:
Click here to enter text.
Name: Click here to enter text.
Social Sec: Click here to enter text.
Street Address: Click here to enter text.
City: Click here to enter text.
State: Click here to enter text.
Zip: Click here to enter text.
Phone: Click here to enter text.
Cell: Click here to enter text.
Texting OK: Choose an item.
Email: Click here to enter text.Emailing OK: Choose an item.
Date of Birth: Click here to enter text.
Height: Click here to enter text.
Weight: Click here to enter text.
Blood Pressure: Click here to enter text.
Race ☐African American ☐Caucasian ☐American Native ☐American Asian ☐European
☐Hispanic ☐Arab ☐Pacific Islander ☐Indian
Preferred Language: Choose an item.
Referring(Eye) Doctor: Click here to enter text.
Date of Last Exam: Click here to enter text.
Primary Reason for this Visit: Click here to enter text.
Primary Eye Diagnosis: Choose an item.Family History of Eye Disease: Choose an item.
Family History of Medical Condition: Choose an item.
Do you Drive: Choose an item.How often? Choose an item.Daytime: Choose an item.
Do you use tobacco products? Choose an item.
Type of product/ years used: Click here to enter text.
Drink Alcohol? Choose an item.How often? Choose an item. Illegal drug use? Choose an item.
Have you been diagnosed with? Choose an item.Pregnant or Nursing: Choose an item.
Do you have eyeglasses? Choose an item.Do you wear them? Choose an item.
Do you wear contact lenses? Choose an item.If Yes, type of lens: Choose an item.
Brand Solution: Choose an item.
Extended wear?(nights without removal) Choose an item.
History of Dry Eye? Choose an item. Currently Using Moisture Drops: Choose an item.
How Often? Choose an item. Relieves Symptoms? Choose an item.
List any other current remedies for dry eye: Click here to enter text.
Please describe any eye symptoms you are experiencing: Click here to enter text.
Please briefly list any other diagnosed health issues: Click here to enter text.
Please give name of person completing this form: Click here to enter text.
Brian M. Celico OD Low Vision Specialist
7150 Greenville Avenue – Suite 305
Dallas, Texas 75231 Phone: 214-265-1111 Fax: 214-265-1189
Pharmacy Information
Pharmacy Name:
Pharmacy Phone: Click here to enter text.
Medication List(Please list all medication you are currently taken, including over the counter,
non-prescription products, oral or topical, including vitamins/nutrient supplements:
Click here to enter text.
Current Prescription Ocular Medications: Click here to enter text.
Prescribing Doctor: Click here to enter text.
☐Check here if you have no know allergies to medication
Please list ALL medications you are allergic to: Click here to enter text.
Describe the type of reaction you have to a specific medication: Click here to enter text.
Patient Name: Click here to enter text.
Patient Signature ________________________________________________________
Date: Click here to enter text.
Primary Insurance:
Policy #
Secondary Insurance:
Policy #
Phone #
Phone #
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF POLICY PRACTICES
Brian M. Celico OD
7150 Greenville Avenue-Suite 305
Dallas, Texas 75231-5185
Contact: Brian M. Celico OD
I acknowledge I have received a copy of Brian M. Celico OD Notice of Privacy Practices
Patient Name: Click here to enter text.
Signature:_____________________________________________________________________
Insurance Signature on File
I certify the information given by me in applying for insurance and/or Medicare payment is true
and correct. I authorize my doctor to act as my agent in helping me obtain payment of my
insurance and/or Medicare benefits, and I request that payment of these benefits be made
either to me or on my behalf to Brian M. Celico OD PA for any services and materials furnished.
I authorize any holder of medical information about me to release to the Centers for Medicare
and Medicaid Services and its agents and information needed to determine these benefits
payable to related services. If I have other health insurance coverage (as indicted in Item 9 of
the HCFA-15000 claim form or electronically submitted claim), my signature authorizes release
of the above medical information to the insurer or agency shown, and authorizes my doctor to
act as my agent, as above.
Patient Signature _______________________________________________________________
Lifetime patient Signature
Date: Click here to enter text.
Brian M. Celico OD
Authorization for Release of Identifying Health Information
Patient Name: Click here to enter text.
Address: Click here to enter text.
Phone: Click here to enter text.
I authorize the professional office of my optometrist named above to release health
information identifying me (including if applicable, information about HIV infection or AIDS,
information about substance abuse treatment, and information about mental health services)
under the following conditions: Detailed description of the information to be released: any
information related to visits to this office.
1. Please list to whom the information may be released: Click here to enter text.
2. The purpose of the release: at the request of the individual.
3. Expiration date or event relating to the individual or purpose for the release: Until
further notice.
It is completely your decision whether or not to sign this authorization form. We cannot refuse
to treat you if you choose not to sign this authorization.
If you sign this authorization, you can revoke it later. The only exception to your right to revoke
is if we have already acted in reliance upon the authorization. If you want to revoke your
authorization, send us a written or electronic note telling us that your authorization is revoked.
Send this note to the office contact person listed at the top of this form.
When your health information is disclosed as provided in this authorization, the recipient often
has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the
information as he/she wishes. Sometimes, state/federal law changes this possibility.
For marketing authorization: we will not receive direct or indirect remuneration from a third
party for disclosing your identifiable health information in accordance with this authorization.
I HAVE READ AND UNDERSTAND THIS FORM. IAM SIGNING IT VOLUNTARILY. I AUTHORIZE THE
DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.
Date: Click here to enter text. Patient Signature _______________________________
If you are signing as a personal representative of the patient, describe your relationship to the
patient and the source of your authority to sign this form.
Relationship to Patient: Click here to enter text.
Print Name: Click here to enter text.
Source of authority: at the request of the individual