Patient History Questionnaire

Northgate Vision Associates - Kristina H. Smith, OD

Patient History Questionnaire

Last Name

First Name

Middle Initial

Preferred Name

Address

City, State, & Zip Code

Date of Birth

Home Phone

Cell Phone

Gender

Email

SSN # (last 4)

Occupation

Employer

Date of Last Eye Exam

Performed by: Dr

Family Physician

How did you hear about us?

Medications (if you have a list, bring it to the front desk to be scanned):

Do you have any allergies?

Do you use cigarettes/tobacco?

Are you pregnant or breastfeeding?

Do you regularly drink alcohol?

Personal and Family Medical History

Have you or a family member been diagnosed with any of the following?
(Relationship = Father, Mother, Brother, Sister, Grandparent)

Diabetes

Family Members

Relationship

High Blood Pressure

Family Members

Relationship

Cataracts

Family Members

Relationship

Glaucoma

Family Members

Relationship

Macular Degeneration

Family Members

Relationship

Retinal Defect/Hole/Tear/Detachment

Family Members

Relationship

Eye Turn

Family Members

Relationship

Other Eye Diseases

Family Members

Relationship

Have you ever had an eye infection, injury, or surgery?

Iritis/Uveitis

Dry Eye

Do you ever see double?

Do you have frequent headaches?

Do you have trouble with night driving?

Do you have color vision issues?

Do you work on a computer?

Are you interested in contacts today?

Have you worn contacts before?

If yes, what type of contacts?

Are you interested in glasses today?

Do you have vision insurance?

Emergency Contact Information & Consent for Release of Medical Information

I

grant permission for the person(s) listed below to have access to all of my medical information pertaining to my care from the physicians of this clinic. This includes, but is not limited to, appointment times, my physician’s plan for my ocular health and all prescriptions, accounting information, etc. In the event of an emergency, please list the names of the individuals you would like us to attempt to contact. If your emergency contact and consent for release of medical information are not the same, please make our staff aware of the changes.

Name

Telephone

Relationship

Name

Telephone

Relationship

Name

Telephone

Relationship

Optomap and Dilating Your Eyes (see clipboard for further information)


As part of a comprehensive eye exam, it is recommended that ALL patients have the internal health of their eyes thoroughly evaluated every year. This is performed as either a dilated retinal examination or the Optomap retinal imaging.

Many patients who choose to have the Optomap will not require pupil dilation, however your doctor will determine if dilation is recommended based on your specific conditions or concerns.

Optomap allows us to capture a picture of the back of each eye, providing us with an excellent baseline to monitor your current and future eye health. We strongly recommend this procedure every year to better help us monitor your eye health, especially if you or any family members have any eye diseases/disorders.

Retinal photos cost $39 and are not covered under most vision plans.

Pupil dilation involves special eye drops that cause your pupils to become larger. This makes it easier for your doctor to see the back of the eye, such as the retina and optic nerve. It takes about 15 to 20 minutes for pupils to fully dilate. Dilation will cause blurry vision for up to 6 hours as well as light sensitivity, which can affect driving and reading

Patient Payment Responsibility

I authorize the release of all medical information necessary to process this claim and that it is pertinent to my medical care. I assign all vision, medical, and/or post-op surgical benefits including major medical benefits to which I am entitled to Dr. Kristina Smith, OD. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is considered as valid as the original. I understand I will be financially responsible for non-covered services and charges.

HIPAA Acknowledgement

I understand that to protect the privacy of my identifiable health information, Kristina H. Smith, O.D. PLLC & Associates, has established a Privacy Policy and guidelines for Privacy Practices within their office. This information explains the use and/or disclosure of information contained in my personal records kept for the purpose of diagnosis, treatment, payment, and health care operations. In accordance with HIPPA regulations, a copy will be provided to me upon request at no charge.

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