Patient History Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address:
City:		State/ZipCode	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:		Work Phone:
Other Phone:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic Partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer/School Name
Misc/Guardian		How did you hear about us?	Existing patient Email Marketing Google Advertisement Google Search Google Search Google Reviews Yelp Insurance Website Word of Mouth Other

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Fr. Miss

Address

City	State	ZipCode
	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary Vision

Insurance Information

Insurance Name:	None AETNA ALASKA CARE ALWAYS VISION AMERIBEN AMERITAS ARIZONA FOUNDATION FOR MEDICAL CARE AZMA GROUP HEALTH & LIFE TRUST BLUE CROSS BLUE SHIELD OF AZ CELTIC INDIVIDUAL HEALTH CHART CIGNA CIGNA MEDICARE ACCESS PLUS COVENTRY HEALTH CARE EYEMED FLEXMED GHI GREAT WEST HEALTHCARE HEALTH NET MEDICARE MEDICARE SECONDARY INSURANCE MINACT MOUNTAIN STATES ADMINISTRATIVE SERVICES NW PLUMBING & PIPEFITTING INDUSTRY HEALTH & WELFAR OPTICARE OF UTAH PREFERRED HEALTH SYSTEMS PRINCIPAL LIFE INSURANCE CO SECURITY HEALTH PLAN SELF PAY STERLING CONNECT 2 PFFS TRICARE UNICARE UNITED HEALTHCARE VETERANS ADMINISTRATION VISION SERVICES PLAN WEA TRUST
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Second Vision

Insurance Information

Insurance Name:	None AETNA ALASKA CARE ALWAYS VISION AMERIBEN AMERITAS ARIZONA FOUNDATION FOR MEDICAL CARE AZMA GROUP HEALTH & LIFE TRUST BLUE CROSS BLUE SHIELD OF AZ CELTIC INDIVIDUAL HEALTH CHART CIGNA CIGNA MEDICARE ACCESS PLUS COVENTRY HEALTH CARE EYEMED FLEXMED GHI GREAT WEST HEALTHCARE HEALTH NET MEDICARE MEDICARE SECONDARY INSURANCE MINACT MOUNTAIN STATES ADMINISTRATIVE SERVICES NW PLUMBING & PIPEFITTING INDUSTRY HEALTH & WELFAR OPTICARE OF UTAH PREFERRED HEALTH SYSTEMS PRINCIPAL LIFE INSURANCE CO SECURITY HEALTH PLAN SELF PAY STERLING CONNECT 2 PFFS TRICARE UNICARE UNITED HEALTHCARE VETERANS ADMINISTRATION VISION SERVICES PLAN WEA TRUST
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Primary Medical

Insurance Information

Insurance Name:	None AETNA ALASKA CARE ALWAYS VISION AMERIBEN AMERITAS ARIZONA FOUNDATION FOR MEDICAL CARE AZMA GROUP HEALTH & LIFE TRUST BLUE CROSS BLUE SHIELD OF AZ CELTIC INDIVIDUAL HEALTH CHART CIGNA CIGNA MEDICARE ACCESS PLUS COVENTRY HEALTH CARE EYEMED FLEXMED GHI GREAT WEST HEALTHCARE HEALTH NET MEDICARE MEDICARE SECONDARY INSURANCE MINACT MOUNTAIN STATES ADMINISTRATIVE SERVICES NW PLUMBING & PIPEFITTING INDUSTRY HEALTH & WELFAR OPTICARE OF UTAH PREFERRED HEALTH SYSTEMS PRINCIPAL LIFE INSURANCE CO SECURITY HEALTH PLAN SELF PAY STERLING CONNECT 2 PFFS TRICARE UNICARE UNITED HEALTHCARE VETERANS ADMINISTRATION VISION SERVICES PLAN WEA TRUST
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Second Medical

Insurance Information

Insurance Name:	None AETNA ALASKA CARE ALWAYS VISION AMERIBEN AMERITAS ARIZONA FOUNDATION FOR MEDICAL CARE AZMA GROUP HEALTH & LIFE TRUST BLUE CROSS BLUE SHIELD OF AZ CELTIC INDIVIDUAL HEALTH CHART CIGNA CIGNA MEDICARE ACCESS PLUS COVENTRY HEALTH CARE EYEMED FLEXMED GHI GREAT WEST HEALTHCARE HEALTH NET MEDICARE MEDICARE SECONDARY INSURANCE MINACT MOUNTAIN STATES ADMINISTRATIVE SERVICES NW PLUMBING & PIPEFITTING INDUSTRY HEALTH & WELFAR OPTICARE OF UTAH PREFERRED HEALTH SYSTEMS PRINCIPAL LIFE INSURANCE CO SECURITY HEALTH PLAN SELF PAY STERLING CONNECT 2 PFFS TRICARE UNICARE UNITED HEALTHCARE VETERANS ADMINISTRATION VISION SERVICES PLAN WEA TRUST
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Third Medical

Insurance Information

Insurance Name:	None AETNA ALASKA CARE ALWAYS VISION AMERIBEN AMERITAS ARIZONA FOUNDATION FOR MEDICAL CARE AZMA GROUP HEALTH & LIFE TRUST BLUE CROSS BLUE SHIELD OF AZ CELTIC INDIVIDUAL HEALTH CHART CIGNA CIGNA MEDICARE ACCESS PLUS COVENTRY HEALTH CARE EYEMED FLEXMED GHI GREAT WEST HEALTHCARE HEALTH NET MEDICARE MEDICARE SECONDARY INSURANCE MINACT MOUNTAIN STATES ADMINISTRATIVE SERVICES NW PLUMBING & PIPEFITTING INDUSTRY HEALTH & WELFAR OPTICARE OF UTAH PREFERRED HEALTH SYSTEMS PRINCIPAL LIFE INSURANCE CO SECURITY HEALTH PLAN SELF PAY STERLING CONNECT 2 PFFS TRICARE UNICARE UNITED HEALTHCARE VETERANS ADMINISTRATION VISION SERVICES PLAN WEA TRUST
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

To save time during your exam, please fill out as much information as possible. Thank you.

CHIEF CONCERN

No vision correctionWears glasses Wears contact lenses

How did you hear about our office? PAST OCULAR HISTORY GlaucomaMacula/Retinal DiseaseCataracts KeratoconusOther ocular disease

Previous ocular surgeries, injuries, or infections PAST MEDICAL HISTORY DiabetesHigh blood pressureCardiovascular diseaseRespiratory DiseaseHigh CholesterolThyroid Disease Other disease

CURRENT MEDICATIONS No current Meds

Vitamins

Over the counter drugs

Allergies NKDA

Family Medical History (Please list condition and who)

Family Ocular History (Please list condition and who)

Name of Family Physician Date of Last Exam

Name of Last Eye Doctor Date of Last Eye Exam

Other information

CONTACT LENSES
Interested in a contact lens exam?Currently wear contact lenses?Soft ContactsRigid Gas Perm Lenses

Brand Name Right Eye Base Curve Power

Brand Name Left Eye Base Curve Power

# Hours worn each day

How often do you throw away the contacts?

How often are you supposed to throw them away?

Do you sleep in your contacts?

SOCIAL HISTORY
Occupation: Hobbies STD
Smoking Status: Never Smoker Current every day smoker Current some day smoker Former smoker Never Smoker Type: None Cigarettes Cigars Chewing Tobacco Other How Long:
Alcohol: No Yes Occasionally Socially Other Type: None Beer Wine Hard Liquor Other How Long:
Illegal Drugs: No Yes Type: How Long:


These questions are solely asked to meet the Government Meaningful Use criteria for electronic medical records and will be used for no other purpose.

Height Feet: Inches: Weight: Preferred Language : Race: Patient Declined to Specify American Indian or Alaska Native Asian Black or African American Asian Native Hawaiian or Other Pacific Islander White Other Race Ethnicity: (Declined) Hispanic or Latino Not Hispanic or Latino

OFFICE POLICIES

By checking this box, I allow Premier Eyecare of Arizona to file medical or vision insurance claims on my behalf. By checking this box, I acknowledge that I will be financially responsible for any balance not paid by my insurance. I also acknowledge that custom eyewear is nonrefundable. By checking this box, I acknowledge that I have read a copy of the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I have read a copy of the Notice of Privacy Practices and Patient Consent Form. Checking this box allows Premier Eyecare of Arizona to conduct normal office procedures in accordance with HIPAA. I have read a copy of the Notice of Privacy Practices and Patient Consent Form. This allows Premier Eyecare of Arizona to conduct normal office procedures in accordance with HIPAA and file insurance claims on my behalf. I acknowledge that I will be financially responsible for any balance not paid by my insurance. SIGNATURE / TYPE YOUR NAME Date Submit Data Please click the "SUBMIT DATA" button and your information will be electronically sent to our office. Thank you.