Date: __________________________________

PATIENT INFORMATION
PRIMARY MEDICAL INSURANCE INFORMATION
_________________________________________________________________
Last Name
First
MI

INSURANCE COMPANY: ___________________________________________________

_________________________________________________________________
Street Address

INSURANCE ID#:__________________________________________________________

_________________________________________________________________
City
State
Zip

GROUP #:________________________________________________________________

Occupation: _______________________________________________________

NAME OF INSURED: _______________________________________________________

DOB: _________________________ Age: _____________ M/F

Relationship to Insured:

PHONE: __________________________________________________________
(Home)
(Cell)

INSUREDS DOB: ________________________________________________

Self

Spouse

Child

Other

SECONDARY MEDICAL INSURANCE INFORMATION

Marital status: S / M / D/ W

INSURANCE ID#:________________________________________________________
INSURANCE COMPANY: _________________________________________________

Email: ____________________________________________________________

NAME OF INSURED: _____________________________________________________

(For appointment reminders, or contact lens sales only)

Relationship to Insured:

If minor, parent name: ______________________________

FT student: Y / N

Self

Spouse

Child

Other

INSUREDS DOB: _______________________________________________________

EMERGENCY CONTACT: ____________________________________________

Name
Phone

HOW WERE YOU REFERRED TO OUR OFFICE?

RELATIONSHIP: ___________________________________________________

____Web Search

PRIMARY CARE PHYSICIAN: _________________________________________

Another patient: ____________________

____Advertisement

____ Insurance Listing

or DR: __________________

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, _____________________________________________________________________, acknowledge that I have received the Notice of Privacy Practices.
(Patients Name)
Signature __________________________________________________________________
Patient, Parent or Legally Authorized Representative

Date __________________________________

Relationship to the Patient: _________________________________________________________________________________________________

Due to HIPPA regulations, please indicate who you would allow the office to release information regarding treatment
while under my care ___________________________________ / _________________________________ relationship.
ASSIGNMENT AND RELEASE
I, the undersigned, certify that I, (or my dependent) have the insurance coverage listed above and assign directly to Dr. Alan Rosenheck all Medicare or other insurance benefits payable for
services rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance. I authorize the Doctor to release any information necessary to secure the
payment of benefits. I authorize the use of this signature on all insurance submissions.
MEDICARE PATIENTS: The fee for refraction of $20.00 is a non-covered expense by Medicare. The 20% secondary fee is not always a covered expense.
Signature of Patient (or parent if minor):____________________________________________________________________
(OVER)

Date ________________

MEDICAL INFORMATION
Do you currently have or ever had a history of any of the following?
PLEASE ANSWER YES OR NO FOR EACH QUESTION
Primary reason for todays visit:

YES

NO

High Blood Pressure

YES

NO

Heart Disease

YES

NO

Diabetes (Type I/Type II)

YES

NO

Yearly eye exam

YES

NO

High Cholesterol

YES

NO

Contact Lens exam

YES

NO

Asthma

YES

NO

Eye Infection/Problem

YES

NO

Migraines/Headaches

YES

NO

LASIK/PRK evaluation

YES

NO

Arthritis

YES

NO

MS

OCULAR/EYE INFORMATION

YES

NO

Lupus

Do you presently have any problems with the following?

YES

NO

HIV

YES

NO

Blurred vision at distance

YES

NO

Cancer

YES

NO

Blurred vision at near

YES

NO

Hepatitis

YES

NO

Eye strain w/computer use

YES

NO

Itching/burning/discharge

YES

NO

Nervous

YES

NO

Red eyes

YES

NO

Mental

YES

NO

Gritty feeling/dryness

YES

NO

Respiratory (lungs/breathing)

YES

NO

Watery eyes

YES

NO

Musculoskeletal (muscles/joints)

YES

NO

Eye pain

YES

NO

Gastrointestinal (stomach/intestines)

YES

NO

Double Vision

YES

NO

Genitourinary (genitals/kidney/bladder)

YES

NO

Glare/Light sensitivity/halos

YES

NO

Endocrine (hormones/glands/thyroid)

YES

NO

Floaters

YES

NO

Hematological (blood/lymph)

YES

NO

Flashes of light

YES

NO

Skin

YES

NO

Problems with night vision/driving

YES

NO

Ears/Nose/Throat

YES

NO

Do you currently wear glasses?

YES

NO

Cardiovascular (heart/blood vessels)

Full Time
YES

Part Time
NO

Distance

Do you have problems with any of these systems?

Close

Do you currently wear contact lenses?

Other (please describe):________________________________________

Brand ______________________________
Have you ever had any of the following? Explain
YES

NO

Eye infection _______________________________

YES

NO

Eye injury/surgery ___________________________

YES

NO

Do you suffer from seasonal or environmental allergies?

CURRENT MEDICATIONS:
____________________________________________________________
____________________________________________________________

Have you ever been told you have any of the following?
YES

NO

Glaucoma

SURGERIES:

YES

NO

High pressure in your eyes

____________________________________________________________

YES

NO

Cataracts

YES

NO

Macular Degeneration

_____________________________________________________________

YES

NO

Retinal holes/tears/degeneration

Does anyone in your family have any of the following conditions?

YES

NO

Retinal holes/tears/degeneration

YES

NO

High Blood Pressure

YES

NO

Keratoconus

YES

NO

Heart Disease

YES

NO

Diabetes

YES

NO

Cancer

YES

NO

Glaucoma

Any other problem not listed: _________________________________________________

Do you?
YES

NO

Smoke _________/day

YES

NO

Cataracts

YES

NO

Drink alcohol _________/day

YES

NO

Macular Degeneration

YES

NO

If female, are you pregnant or nursing?

YES

NO

Retinal problems

YES

NO

Are you allergic to any medication(s)

YES

NO

Blindness

Other: _______________________________________________________
If yes, list name of medication:
__________________________________________________________________________

Date of last eye exam: _________________ Dr: _____________________

__________________________________________________________________________

Date of last dilation: ____________________________________________

An eye exam includes dilation of the pupils. This routine procedure consists of using drops to dilate the pupils (make them temporarily larger). This allows us to evaluate
the retina more completely. Glaucoma, retinal holes or tears, and certain degenerations can have no symptoms. If not detected, these problems can be vision
threatening. The effects of the drops last a few hours after installation. You will be sensitive to bright lights, and blurred, especially for near vision.