Drs. Whitley & Hughes

WELCOME Appointmenl Date_

PATIENT REGISTRATION

Patient

Address

State City

Home phone number '.—

Work phone number _ _ _

Cell phone number

Email Address .

Sex • M • F Birthdate_

Social Security number

Occupation .

Employer .

Employer Address . ,

Employer Phone

Spousfe's Name .

Bir thday

Occupation

Spouse's Employer .

Zip

ss#.

IN CASE O F E M E R G E N C Y , C O N T A C T

Name "

Relationsliip ]

Phone Number H W

STEP 3

PLEASE COMPLETE BOTH SIDES OF THIS

QUESTIONNAIRE BY FOLLOWING THE

THRFF EASY STEPS IN BLACK INK

Step 2 INSURANCE

Who is responsible for this account?

Relationship to patient ,

Birthdate ^ SS#

Insurance Company

Group number c

Is patient covered by additional insurance

Subscriber name

Birthdate- SS#

Relationship to patient

Insurance Company

Group' number .

• Y O N

ASSIGNMENT AND R E L E A S E I, ihe undersigned certify that 1 (or my dcpendenl) have insurance coverage with .

_and assign direcdy to Drs. Whitley & Hughes a insurance benefits, if any, otherwise payable to me for service rendered. 1 imderstand that I am flnanclally responsible tor all charges whether or not paid by Insurance. 1 hereby authorize the use of this signature on all insurance submissions.

Responsible Party Signature Date

MEDICAL AUTHORIZATION I request that payment of authorized Medicare benefits be made on my behalf to Drs. Wtiitley & Hughes for services furnished to me by Drs. -WhlUey & Hughes. 1 authorize any holder of medical information about me to release to the Division of Medicare and Medicaid Services and its agents any information needed to determine those benefits pay, able for related services. 1 understand my signature requests that payment be made and authorizes release of medical Informatioo necessary to pay the claim. If "other health Insurance" Is indicated In item 9 of the HCFA-iSOO form, or elsewhere on other approved claim forms or electronlcaiiy submitted claims, my signature authorizes releas-ing of their information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determinarion of the Medicare carrier as the full charge, and non-covered services. Coinsurance and the deductible are based upon the charge determinarion ofdhe Medicare carrier,

Responsible Party Signature Date

MEDICAL HISTORY QUESTION PAST PERSONAL HISTORY

MEDICATIONS

n • • Diaig Al lergies,

•

•

Q

PRIMARY C A R E PHYSICIAN INFORMATION

Describe all senous illnesses, injuries and surgeries:

Names

Address '

Phone Number

Date of last eye exam

Name of previous eye doctor

Fax

STEP 3 MEDICAL fflSTORY QUESTION

FAMILY H I S T O R Y

Please note any family member witti the following diseases/ conditions: M-Motlier, F-Father; S-Slbiling, GP-Grandparent

S O C I A L fflSTORY

Arthritis

Blindness

Cancer

Cataracts

Crossed Eyes

• • Diabetes

• Glaucoma

• • Heart Disease

• • Hypertension

• • Retinal Dz.

• • • •

n D

• •

• •

Health Habits

Check which substances you use and the consunaption.

YES NO

Social History Please indicate hQbbies and interest;

YES NO

Alcohol Quantity:

Drugs Quantity:

Tobacco Quantity:

• •

• •

a •

Computers

Fishing

Golfing

Hunting

Music

Reading

• • • • • Q • • • • •

SOCIAL HISTORY

Check the symptoms and/or condit ions you currently have or have had in the past.

EYES YES NO tJNKNOWN

Blurred Vision n • • Burning • • Cataracts • • Crossed Eyes ' • • • Distorted Vision (Halos) • a • Double Vision a a • Dryness • o • Excess Tearing/Watering • 9 • Eye Pain or Soreness • • ... • Flashes/Floaters in Vision D • • Foreign Body Sensation • • • Glare/Light Sensitivity • • D Glaucoma • • • Infection of Eye or L id a • • Itching • D • Lazy Eye • • • I^ss of Vision • • • Mucous Discharge • • a Redness n • a Retinal Disease • • • Sandy or Gritty Feeling • • • • • Styes or Chalazion • a •

BONE/JOINT/MUSCLE Arthritis • • • Jpint/Muscie Pain • • • Polio • . • •

CANCER Breast • • • Lujig • • • Pro'state • • • Skin • o •

CONSTITUnONAJL Fever • • Q Weight Gain/Loss • • •

•ENDOCRINE •

Tliyroid Abnormalities • • • EAR, NOSE, AND THROAT

• Allergies • • • Chronic Cough • D • Dry Mouth/Throat D • • Hay Fever • • • • Runny Nose • • D Sinus Congestion • • •

GASTROINTESTINAE (Stomach)

Constipation

Diarrhea

Ulcers GENITOURINARY

Cfdamydia Gonorrhea Kidney Disease Syphilis

INTEGUMENTARY (Skin) Eczema Psoriasis

LYMPHATIC/HEMATOLOGIC AIDS Anemia Bleeding Disorders Hepatitis Herpes HIV Positive Liver Disease

NEUROLOGIC Epilepsy Headaches Migraines Multiple Sclerosis Seizures

PSYCHIATRIC Depression High Anxiety

REPRODUCTIVE Nursing Mothel Pregnant

RESPIRATORY Asthma Ctironic Bronchitis Emphysema Pneumonia Tuberculosis

VASCULAR Diabetes Heart Disease High Blood Pressure High Cholesterol Stroke

Please sign below tha, you have reviewed all information it is correct toliT^;;^;?;;^;;;;;^

YES NO UNKNOWN

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FOR DOCTOR'S USE:

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