HIPPA FORM FILL - Missouri Eye Consultants

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Welcome to Our Practice

Appoinment Date(Required)

Appointment Time:(Required)

:

Name(Required)

Today's Date(Required)

Address(Required)

Street Address City ZIP / Postal Code

Email(Required)

Phone(Required)

Employer(Required)

Birth Date(Required)

Guardian (If Applicable)

Social Security #:(Required)

Medical Doctor(Required)

Occupation(Required)

Last Eye Exam:(Required)

Emergency Contact Name(Required)

Emergency Contact Phone Number(Required)

How did you hear about our practice:

Recommended by friend or family

Your insurance Provider List

Referral from your doctor

Internet / Our website

Phone book

Other

We are providers for Medicare, Missouri Medicaid, Essence, Cigna, Blue Cross/Blue Shield, Vision Care Direct, UMR, United Healthcare, Coventry, Humana, Healthlink, VSP, EyeMed, Delta Vision, NVA, and Advantica. If you have other insurance, we will provide you with an itemized receipt on the day of your examination that you may file with your insurance company. If you do not have one of the plans we accept, payment is requested on the day services are rendered.

Vision Insurance Carrier:

(the staff will need to make a copy of your insurance card)

SOCIAL HISTORY

This information is kept strictly confidential. If you prefer, you may discuss directly with your doctor.

Do you use tobacco products?(Required)

No

If yes, type amount / how long:

I used tobacco explanation(Required)

Do you drink alcohol?(Required)

No

If yes, type amount / how long:

I drink alcohol explanation(Required)

Do you use illegal drugs?(Required)

No

If yes, type amount / how long:

I use Illegal drugs explanation(Required)

FAMILY HISTORY

Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:

DISEASE/CONDITION

Relationship for Blindness(Required)

Relationship for Cataract(Required)

Relationship for Crossed Eyes(Required)

Relationship for Glaucoma(Required)

Relationship for Macular Degenaration(Required)

Relationship for Retinal Detachment(Required)

Relationship for Cancer(Required)

Relationship for Diabetes(Required)

Relationship for Thyroid Disease(Required)

Relationship for High Blood Pressure(Required)

Other Disease/Condition

Relationship to you

REVIEW OF SYSTEMS

Do you currently, or have you ever had any problems in the following areas:

CONSTITUTIONAL

EARS, NOSE, MOUTH, THROAT

NEUROLOGICAL

RESPIRATORY

EYES

	NO	YES	?
Loss of Vision
Blurred Vision
Loss of Peripheral Vision
Double Vision
Mucous Discharge
Red Eyes
Itching
Glare / Halos / Light Sensitivity
Chronic Eye Infections
Flashes/Floaters
Computer Eye Strain
Dry Eyes

CARDIOVASCULAR

ENDOCRINE

	NO	YES	?
Thyroid/Other Glands

GASTROINTESTIONAL

GENITOURINARY

	NO	YES	?
Genitals/Kidney / Bladder

BONES/JOINTS / MUSCLES

BONES / JOINTS / MUSCLES

LYMPHATIC

CAPTCHA

	NO	YES	?
Allergies/Hay Fever
Sinus Congestion
Dry Mouth/Throat

	NO	YES	?
Headaches
Migraines
Seizures

	NO	YES	?
Anemia / Bleeding Problems
ALLERGIC/IMMUNOLOGIC
PYSCHIATRIC

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Welcome to Our Practice

MEDICAL HISTORY

SOCIAL HISTORY

FAMILY HISTORY

REVIEW OF SYSTEMS

	NO	YES	?
Blindness
Cataract
Crossed Eyes
Glaucoma
Macular Degeneration
Retinal Detachment
Cancer
Diabetes
Thyroid Disease
High Blood Pressure

	NO	YES	?
Fever, Weight Loss/Gain
INTEGUMENTARY (Skin)

	NO	YES	?
Asthma
Emphysema

	NO	YES	?
Diarrhea
Constipation