Patient Name Social Security Number: Date of Birth: Age: Street Address: Apt. # City State Zip Home Phone: ( ) -- Mobile Phone: ( ) -- Employer Name and Address City State Zip Business Phone ( ) -- Occupation Name of Spouse or Guardian Emergency Contact Name and Phone How were you referred to Dr. Goren? Primary Care doctor name and phone &/or address Pharmacy name and phone &/or address:
Past Medical History (Please circle all that apply) Anxiety Hepatitis Arthritis Hypertension Artificial joints HIV/AIDS Asthma Hypercholesterolemia Atrial fibrillation Hyperthyroidism BPH Hypothyroidism Bone marrow transplantation Leukemia Breast cancer Lung cancer Colon cancer Lymphoma COPD Pacemaker Coronary artery disease Prostate cancer Depression Radiation treatment Diabetes Seizures End stage renal disease Stroke GERD Valve replacement Other Please list any major surgeries you have had (NOT eye surgery): Please list any eye disease/condition for which you have been diagnosed/treated and which eye: Please list any eye surgeries you have had and which eye:
Family Eye History (Please circle all that apply): Blindness Cataracts Diabetes Glaucoma Macular Degeneration Migraine Retinal Detachment None Eye Drops (Please indicate name of medication, which eye and how many times a day used) Other Medications (Please list all current medications): Allergies Please enter all allergies to medications and briefly describe what happened when you took it:
Social History (Please circle all that apply): Cigarette Smoking: Alcohol Use: Never Smoked Quit Former smoker Smokes less than daily Smokes daily None Less than 1 drink a day 1-2 drinks a day 3 or more drinks a day Review of Systems Are you currently experiencing any of the following? Pacemaker Yes No Jaw pain Yes No Scalp tenderness Yes No Fever Yes No Chills Yes No Weight loss Yes No Stuffy nose Yes No Earache Yes No Cough Yes No Dry mouth Yes No Rapid heart beat Yes No Congestion Yes No Wheezing Yes No Shortness of breath Yes No Upset stomach Yes No Bowel difficulties Yes No Urinary difficulties Yes No Joint pain or stiffness Yes No Headaches Yes No Seizures or Stroke Yes No Anemia Yes No Hay fever Yes No Hives Yes No Other non-eye symptoms not mentioned:
Primary Insurance ID # Group # Name of insured (if different from patient) Insured s date of birth: Insured s Social Security # Relationship to patient: Spouse Parent Legal Guardian Secondary Insurance ) ID # Group # The information I have provided above is current as of my visit today. Should any information change, I agree to contact this office immediately. By signing this document, I (1) authorize Goren Eye Associates to bill my insurance company for services rendered and (2) I accept responsibility for all balances in full, including but not limited to co-payments, amounts applied to my deductible or procedures not covered by my insurance, SUCH AS REFRACTIONS. (PLEASE INITIAL & DATE)
******************************************************************************************************* NOTICE OF PRIVACY PROCEDURES ACKNOWLEDGEMENT I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: (1) Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly; (2) Obtain payment from third-party payers; and (3) Conduct normal healthcare operations such as quality assessments and physician certifications. I have received your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Private Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. Patient Name: Relationship (if different than patient: Signature: Date: (For Office Use Only) Patient refused to sign: