Appointment Request1 - IMAGINE Optometry

P A T I E N T I N F O R M A T I O N

Name

Address

Email

Gender

F

M

Age

Race

Asian Specify

East Asian Or Indian

Hispanic Or Latino

White

Black Or African American

Decline To Specify

Not Listed(Specify)

Occupation/Field Of Study

Hobbies, Intersts, Sports

Who may we thank for referring you?

Internet

Patient

Other:

P R I M A R Y I N S U R A N C E

Member’s Name

Type of Vision Insurance:

Member’s ID# or SSN:

Member’s Birthdate:

Patient Relationship to Insured

Self

Spouse

Child

I understand that I am financially responsible for all fees for services provided and authorize payment of my medical benefits to IMAGINE Optometry for services rendered. If additional services are required (i.e. contact lens service, medical eye

Signature:

Date

Print Name

Relationship

Self

Parent

Guardian

P H O N E N U M B E R S

Home

Cell

Work

E Y E C A R E H I S T O R Y

Date of Last Eye Exam:

Do you wear Glasses?

Yes

No

Do you wear Contact Lenses?

Yes

No

If yes, how old are your Glasses?

If yes, how old is your current pair?

Do you plan to get new Glasses today?

Yes

No

If no, are you interested in Contact Lenses?

Yes

No

Have you had Laser Refractive Surgery?

Yes

No

Do you experience symptoms of Dry Eye?

Yes

No

If no, are you interested in Refractive Surgery?

Yes

No

Office use only - SPEED Score

O C U L A R H E A L T H & R E V I E W O F S Y S T E M S

Date of Last Physical Exam:

Type of Health Insurance

Do you currently, or have ever had any problems in the following areas? Mark Ye s, No or Family. Marking Family would indicate you have a parent or sibling that currently has the listed condition

Glaucoma

Yes

No

Family

Macular Degeneration

Yes

No

Family

Retinal Disease

Yes

No

Family

Strabismus

Yes

No

Family

Amblyopia (lazy eye)

Yes

No

Family

Eye Injury

Yes

No

Family

Dry Eyes

Yes

No

Injury

Double Vision

Yes

No

Flashes / Floaters

Yes

No

Eye Itch/Burn

Yes

No

Eye Surgery

Yes

No

If you answered Ye s or Family to any of the above or have any other conditions not listed, please provide some additional details below:

Do you use tobacco products?

Yes

No

Do you consume 2 or morealcoholic beverages per day?

Yes

No

Allergy / Immune (hay fever, immune deficiency)

Yes

No

Cardiovascular / Vascular(heart disease, high cholesterol / blood pressure)

Yes

No

Constitution (general illness / cancer)

Yes

No

Ear, Nose, Throat(sinus congestion, sore throat)

Yes

No

Endocrine (diabetes, thyroid, hormone dysfunction)

Yes

No

Gastrointestinal (chronic diarrhea, ulcers)

Yes

No

Genitourinary (kidney / bladder)

Yes

No

Hematologic / Lymphatic(anemia, bleeding problems)

Yes

No

Integumentary (rosacea, eczema)

Yes

No

Musculoskeletal (arthritis, back pain)

Yes

No

Neurological (headaches, migraines, seizures)

Yes

No

Psychiatric (depression, anxiety)

Yes

No

Respiratory (asthma, emphysema, chronic bronchitis)

Yes

No

Women

Are you pregnant?

Yes

No

Due Date

Are you nursing?

Yes

No

A L L E R G I E S

No Known Drug Allergies

Latex

Seasonal Allergies

Aspirin

Penicillin

Sulfa

Other

M E D I C A T I O N S

List anymedications you are currently taking and the corresponding health condition:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

In the course of providing service to you, we create, receive, and store health information that identifies you. It is often necessary to use and disclose information in order to treat you, to obtain payment for our services, and to conduct healthca

I acknowledge that I have received IMAGINE Optometry’s Notice of Privacy Practices.

Signature:

Date

Signature

Patient

Parent

Guardian

Doctor's Signature

Date

patient registration form