Microsoft word - 491c8287-6d5d-0823b4.doc

Patient Data Sheet
Patient Information
MR. MS. MRS. MISS (circle one) First Name _______________________ Last Name __________________________ M_____ Address__________________________________________________ City ______________________________ State ______ Zip_________ Sex M F Age ______ DOB____________ SS#_____________________ Hm Ph.#_____________________ Bus Ph.#____________________ Cell# __________________ Employer _______________________________ Occupation ______________________________ E-Mail Address _________________________________________________________________ Whom may we thank for referring you?_______________________________________________ Who is your current eye doctor?___________________________________Phone#____________ Has your current eye doctor ever suggested LASIK eye surgery to you? Y N Name _____________________ Relationship ________________ Phone#____________________ • How long have you been considering LASIK or another vision correction option? __________________________________________________________________________ • Have you been told in the past that you were a candidate for LASIK and if so, how long ago __________________________________________________________________________ • What prompted you to schedule your consultation with our practice? ___________________________________________________________________________ ___________________________________________________________________________ • What activities will you be able to more fully participate in after your vision is corrected? ___________________________________________________________________________ ___________________________________________________________________________ • What is most important to you in making a decision to have your vision surgically corrected? ___________________________________________________________________________ ___________________________________________________________________________ • What is your desired outcome from today’s visit? ____________________________________________________________________________ ____________________________________________________________________________ Patient Data Sheet
Assignment and Release
¾ Refractive procedures are elective and not generally covered by insurance. I understand that unless there is a contractual obligation or prior agreement if you should file my insurance or agree to any alternative form of payment including payment from any third party I am still ultimately responsible for and guarantee the payment of all fees owed. ¾ During a refractive consultation it may be necessary to dilate my eyes to confirm my candidacy. Dilating drops may blur vision for a length of time that varies from person to person. I authorize Dr. Updegraff and/or his associates to administer dilation drops during any of my consultation ¾ Should I choose to schedule surgery, I understand that I am responsible for a scheduling deposit ¾ In the event that I must cancel my surgical date, I understand that my scheduling deposit is refundable up to 48 hours prior to the scheduled procedure. ¾ I acknowledge that I have received your Patient Information Privacy Notice. ¾ I understand this is an initial consultation only to determine my candidacy for a refractive procedure. Unless I follow up with surgery or regular office visits no doctor patient relationship has been established and no information from this consult will be released to anyone. ___________________________________ _________________________ HEALTH HISTORY FORM
NAME: ______________________________________
DATE: _____________________
YES NO HEART ATTACKS/ ANGINA WITHIN LAST 2 YEARS NO PERMANENT DEFECT FROM ILLNESS, DISEASE OR INJURY NO DO YOU SMOKE_____PKS PER DAY_____ WK_____ MO _____ YES NO ARE YOU TAKING OR HAVE YOU TAKEN SABRIL?YES NO ARE YOU USING LATISSE? NO DO YOU DRINK _____# PER DAY_____WK _____ MO _____ HEIGHT____ WEIGHT ____
PLEASE LIST ALL MEDICATIONS YOU ARE TAKING AND THE DOSAGE:
ALLERGIES: ________________________________________________________________________________________
SURGICAL HISTORY (Please include Date and Type)
PROBLEMS WITH ANESTHESIA YES _____ NO _____
OCULAR HISTORY (HAVE YOU BEEN DIAGNOSED WITH ANY OF THE FOLLOWING IN THE PAST?)
NO CORNEA DISEASE _______________________________ NO GLAUCOMA ____________________________________ NO INJURY ________________________________________ YES NO IRITIS ___________________________ NO OTHER EYE DISORDERS _________________________ CATARACT SURGERY (date of surgery) RIGHT _________ RETINA SURGERY (Date of surgery) RIGHT ____________ FAMILY HISTORY (has anyone in your family (blood relative) has any of the following?) (NOTE RELATION TO PATIENT: F- Father M- Mother P-Paternal M- Maternal S- Sister B- Brother GF- Grandfather GM-Grandmother U- Uncle A- Aunt) YES NO GLAUCOMA ________________________YES NO CATARACTS ____________________ NO HEART PROBLEMS ____________________________________ NO DIABETIC RETINOPATHY ______________________ NO RETINAL DETACHMENT _______________________ YES NO RETINITIS PIGMENTOSA _______________ NO STROKE ______________________________________ NO OTHER GENERAL HEALTH PROBLEMS __________ PRIMARY CARE PHYSICIAN:
PATIENT SIGNATURE: ______________________________ CONTACT PHONE NUMBER: ____________________________
TECH/ DR. NAME:
DATE UPDATED/REVIEWED: _______________________
CHANGES IN MEDICAL HISTORY OR MEDICATIONS SINCE LAST VISIT: YES _______ NO ______ CHANGES THAT HAVE OCCURRED: ___________________________________________________________________________________ _______ ___________________________________________________________________________________________________

Source: http://www.lasik4me.com/pdf/patient-form.pdf