Welcome To Professional Family Eyecare Patient InformationToday’s Date: MM slash DD slash YYYY Name First Middle Last Sex M F Date of Birth MM slash DD slash YYYY AgeAddress Street Address City State / Province / Region ZIP / Postal Code Home/Daytime PhoneCell PhonePatient’s SSNEmployer (or School) Occupation (or Grade) Email Address Parent’s Name for MinorsName First Last Name First Last Whom may we thank for referring you to our office? What is your preferred method of contact? What is the major purpose of this visit? Eye Exam HistoryDate of Last Eye Exam MM slash DD slash YYYY By Whom? Do you currently wear contact lenses? Yes No Family Eye/Medical History (Check all that apply)Is there a family history of any of the following: Maternal/Paternal BlindnessMaternal/Paternal Retinal ProblemsMaternal/Paternal GlaucomaMaternal/Paternal Macular DegenerationMaternal/Paternal Corneal ProblemsMaternal/Paternal DiabetesMaternal/Paternal Other Patient Financial ResponsibilityI hereby authorize Professional Family Eyecare to apply my vision benefits on my behalf for covered services rendered. I agree to assume responsibility of full payment pending any balance that is not covered by insurance company. Patient or Guardian’s SignatureSignedPrimary Care InformationPrimary Care Doctor: First Last Primary Phone Number:Primary’s Location: Street Address City State / Province / Region ZIP / Postal Code Medical HistoryCURRENT MEDICATIONS (List name of medications including eye drops, vitamins, over the counter and birth control pills): Add RemoveList all allergies (seasonal/medications) Add RemoveDo you use:Alcohol? Yes No Other substances? Yes No Cigarettes/ Tobacco? Yes No When did you start smoking? Have you ever been diagnosed or treated for the following health problems?Arthritis Yes No please specify Cancer Yes No please specify Type Cholesterol Yes No please specify Diabetes (Insipidus/Mellitus) Yes No please specify High Blood Pressure Yes No please specify Integumentary (Skin) Yes No please specify Kidney Yes No please specify Neurological Yes No please specify Psychological Yes No please specify Respiratory Yes No please specify Thyroid (Hyper/Hypo) Yes No please specify Other Yes No Eye Health HistoryHave you ever experienced, been diagnosed, or treated for any of the following? Cataracts Retinal Detachment Glaucoma Diabetes Macular Degeneration Double Vision Crossed eye / Eye turn Eye Infections Flash of light / Floaters Tearing Itchiness Corneal Abrasions HIPAA Compliance Acknowledgement of Receipt of Privacy NoticeProfessional Family Eyecare respects the privacy of your medical records and will do all that we can to secure and protect that privacy. I have reviewed or received a copy of the Notice of Privacy Practicefrom Professional Family Eyecare. I authorize Professional Family Eyecare to use my information to submit my vision benefit claim.Signed