Patient History Form Welcome to Mascoutah Eye CarePATIENT HISTORYToday’s Date: MM slash DD slash YYYY Name First Middle Last Birth Date: MM slash DD slash YYYY Age: Home Phone:Work/Cell:Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Hours Computer Use/Day: Marital Status: Single Married Other If under the age of 18, Parents Name: INSURANCE INFORMATION:Vision Insurance: If you do not inform us that you have a vision plan before services are rendered , we will assume no coverage exists. Patient will be responsible for payment at time of service. Please verify benefits with your vision insurance company . Social Security #: Primary Card Holder: Primary’s Birth Date: MM slash DD slash YYYY Employer: VISUAL AND MEDICAL HISTORY:Reason for today’s visit: Glasses Exam Contact Lens Exam Red Eyes Other Glasses currently worn: Distance Only Near Only Bifocal No-line Bifocal Trifocal Date of last eye exam: MM slash DD slash YYYY Name of Doctor: First Last Are you interested in learning about Lasik Surgery? Yes No Date of last medical exam: MM slash DD slash YYYY Name of Doctor: First Last Medications you are currently taking (including over-the-counter): Please list any drug allergy: Seasonal allergy: Yes No Do you smoke? Yes No Smoking frequency: Please check the following that apply to you and/or your immediate family members:Diabetes SELF FAMILY (List Relationship) High Blood Pressure SELF FAMILY (List Relationship) Arthritis SELF FAMILY (List Relationship) Thyroid SELF FAMILY (List Relationship) Heart Disease SELF FAMILY (List Relationship) Respiratory Problems SELF FAMILY (List Relationship) Kidney Disease SELF FAMILY (List Relationship) Eye Injury SELF FAMILY (List Relationship) Floaters/Flashes SELF FAMILY (List Relationship) Double Vision SELF FAMILY (List Relationship) Headache SELF FAMILY (List Relationship) Lazy Eye SELF FAMILY (List Relationship) Cataract SELF FAMILY (List Relationship) Glaucoma SELF FAMILY (List Relationship) Retinal Disease SELF FAMILY (List Relationship) Macular Degeneration SELF FAMILY (List Relationship) Eye Surgery SELF FAMILY (List Relationship) Cancer SELF FAMILY (List Relationship) Others: SELF FAMILY (List Relationship) Surgery: SELF FAMILY (List Relationship) what kind ? what kind ? what kind ? what kind ? what kind ? what kind ? Do you have: *dry eyes? Yes No *itchy eyes? Yes No *excess tearing? Yes No Do you skip lines or lose your place when reading? Yes No CONTACT LENS INFORMATION:Do you currently wear contact lenses? Yes No what type? How often do you replace your contact lenses? Do you sleep in your contacts? Yes No Are you interested in bifocal/multifocal contact lenses? Yes No YOU MUST READ AND SIGN THIS SECTION Financial Assignment & ReleaseMascoutah Eye Care I, the undersigned, assign directly to Mascoutah Eye Care or Dr. Marianne McDaniel all insurance benefits, if any, otherwise payable by me or to me for services rendered.*I understand that I am financially responsible today for all fees. I also agree that I am financially responsible to reimburse any and all fees for services and materials not collected in full at the date of service or should my insurance or vision plan deny payment for services or materials rendered.*I further understand that after 60 days from the date of service or claim is filed I agree to pay for any unpaid balances on my account as a result of denial in part or whole from my insurance carrier caused by; unmet deductibles, non-covered materials or professional services, my negligence in fulfilling any paperwork, providing any required information requested of me by my insurance carrier or uncollected fees on service day.*If you do not inform us that you have a vision plan or medical insurance before services are rendered, we will assume no coverage exists.* I agree that I am responsible to file my own claim if I discover I have vision or medical benefits after services or products are rendered.*We will begin your custom glasses order immediately after receipt of payment. All glasses are custom crafted for each patient’s unique vision needs. All glasses lenses are tailored to fit the frame with patient selected *Cancellations on glasses will not be permitted. Patients may not switch frames after their order has been processed. REFUNDS ARE NOT AN OPTION.Signature of Responsible Party and Consent to Treat:Starting April 14, 2003, Federal law requires us to inform you of privacy practices regarding patients’ records. Copies of these privacy practices are posted in our waiting room. Please print and sign this form that state you have been informed of this regulation. Thank you for your cooperation.Name First Last SignatureMascoutah Eye Care is committed to offering our patients the most through eye health examination available. We now offer optomap® ultra-wide field digital retinal imaging to obtain an in-depth view of nearly the entire retina through an undilated pupil. As part of your comprehensive evaluation, optomap® helps Dr. McDaniel better view and detect ocular disease and abnormalities, such as macular degeneration, glaucoma, retinal holes, retinal detachments and diabetic retinopathy, in the retina at an earlier and more treatable stage than methods previously available Your image will be obtained today as part of our preliminary testing. Your doctor will review and discuss the optomap® images during the exam. In most casesIn most cases this technology may alleviate the need for dilation and allows the patient to return to normal activities. Optomap® i is prescribed annually by Dr. McDaniel on each patient in order to identify eye health problems and compare changes from year to year. At Mascoutah Eye Care we consider optomap® retinal evaluation an important part of our patients’ eye health examination.Optomap® is an advanced screening procedure that is traditionally not covered by most vision insurance plans. Your fee for this elective diagnostic technology will be $39 unless covered by your insurance. The doctor will let you know if this procedure is covered by your insurance when the image is reviewed. I elect to utilize optomap® technology today I decline the use of the optomap® technology and elect for a regular dilated exam Patient or parent/guardian signature Date MM slash DD slash YYYY Due to the rising cost of credit card processing, our pricing reflects a cash discount when paying with cash or check. Credit or debit card transactions will be processed at the unadjusted price and will not be eligible for the 4% discount. Thank you for your understanding