Patient Form 01 - Medical History

MOUNTAINEER VISION CENTER, PLLC

827 Fairmont Road, Suites 105 & 106 - Morgantown, WV 26501 Phone: (304) 296 – 3333; Fax: (304) 296 – 2220 http://www.mvcpllc.com

MEDICAL HISTORY PATIENT’S NAME: __________________________________________________

DATE: ____________________________

- PART ONE DO YOU HAVE ANY OF THE FOLLOWING MEDICAL CONDITIONS? CONDITION

YES

NO

MEDICATIONS

HOW LONG

HYPERTENSION HEART DISEASE STROKE DIABETES THYROID DISEASE ARTHRITIS SINUSITIS EMPHYSEMA ASTHMA KIDNEY DISEASE HEADACHE HEAD INJURY LIVER DISEASE SEIZURES/TREMORS LUPUS ROSACEA HIGH CHOLESTEROL CANCER

- PART TWO DO YOU HAVE ANY OF THE FOLLOWING EYE CONDITIONS? CONDITION

YES

NO

MEDICATIONS

HOW LONG

GLAUCOMA MACULAR DEGENERATION CATARACTS RETINAL DETACHMENT EYE INJURIES EYE SURGERIES BLINDESS LAZY EYE

PLEASE CONTINUE TO THE NEXT PAGE.

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Reviewed By: _________ Date: ________

- PART THREE DO ANY OF YOUR FAMILY MEMBERS HAVE ANY OF THESE MEDICAL CONDITIONS? CONDITION HYPERTENSION HEART DISEASE STROKE DIABETES GLAUCOMA CATARACT RETINAL DETACHMENT EYE SURGERIES BLINDNESS MACULAR DEGENERATION

YES

NO

WHICH FAMILY MEMBERS

- PART FOUR GENERAL QUESTIONS TO ASSIST US IN MEETING YOUR NEEDS & CONCERNS HERE AT THE OFFICE. 

PLEASE LIST THE REASON FOR YOUR VISIT TODAY ON THE LINE BELOW: ______________________________________________________________________________________________



IF YOU ARE ALLERGIC TO ANY MEDICINES, PLEASE LIST THEM ON THE LINE BELOW: ______________________________________________________________________________________________



DO YOU HAVE ANY AIRBORNE ALLERGIES? (PLEASE CIRCLE):



IF YOU USE PRESCRIPTION OR OVER-THE-COUNTER MEDICINES FOR ALLERGIES, PLEASE LIST ON THE LINE BELOW: ______________________________________________________________________________________________

 

ARE YOU PREGNANT? DO YOU SMOKE? DO YOU USE BIRTH CONTROL?



YES

(PLEASE CIRCLE) (PLEASE CIRCLE) (PLEASE CIRCLE)

YES YES YES

NO

NO NO NO

IF YES, PLEASE STATE THE BRAND: _________________________________________________________________

- PART FIVE PATIENT INFORMATION – PLEASE FILL OUT FULLY & COMPLETELY. THANK YOU. PATIENT’S INFORMATION FIRST NAME: _____________________________ MI: _______ LAST NAME: ___________________________________ ADDRESS: ___________________________________________________________________________ APT #: ________ CITY: ________________________________________ HOME PHONE: ______________

STATE: ________

ZIP CODE: ____________

WORK PHONE: ______________ CELL PHONE: __________________________

E-MAIL: _____________________________________________________________________________________________ OCCUPATION: ________________________________ DATE OF BIRTH: ____________________ AGE: ______________ EMPLOYER/SCHOOL: ____________________________________________

GENDER: MALE OR FEMALE

SOCIAL SECURITY NUMBER: ____________________________________________________ FAMILY DR.: _________________________________________

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FAMILY DR. PHONE #: __________________________

Reviewed By: _________ Date: ________

REFERRAL INFORMATION HOW DID YOU HEAR ABOUT US (CIRCLE ONE)? YELLOW PAGES DAILY ATHENAEUM WALKED IN TO CENTER

NEWSPAPER AD MVC, PLLC WEBSITE OTHER

DO YOU HAVE A COUPON?

YES

NO

FRIEND/CO-WORKER / REFERRAL (LIST BELOW): ________________________________________ (IF YES, PLEASE PRESENT TO RECEPTIONIST.)

INSURANCE CARRIER INFORMATION MARITAL STATUS (PLEASE ONLY CIRCLE ONE):

PRIMARY VISION INSURANCE: WHO IS THE PRIMARY POLICY HOLDER? SECONDARY VISION INSURANCE: WHO IS THE PRIMARY POLICY HOLDER?

PRIMARY MEDICAL INSURANCE: WHO IS THE PRIMARY POLICY HOLDER?

SINGLE MARRIED LEGALLY SEPERATED

__________________________________ SELF

ID #:

___________________

OTHER: ____________________________________________

__________________________________ SELF

___________________

OTHER: ____________________________________________

__________________________________ SELF

ID #:

DIVORCED WIDOWED

ID #:

___________________

OTHER: ____________________________________________

- PART SIX PATIENT FINANCIAL RESPONSIBILITY – PLEASE READ CAREFULLY AND SIGN BELOW. THANK YOU. I, HEREBY AUTHORIZE MOUNTAINEER VISION CENTER, PLLC TO APPLY FOR BENEFITS ON MY BEHALF FOR COVERED SERVICES RENDERED BY THEM. I ALSO ASSIGN MY BENEFITS AND REQUEST THAT ALL PAYMENTS FROM MY INSURANCE COMPANY BE MADE DIRECTLY TO MOUNTAINEER VISION CENTER, PLLC. I AGREE TO ASSUME RESPONSIBILITY OF FULL PAYMENT PENDING ANY REMAINING BALANCE THAT IS NOT COVERED BY MY INSURANCE COMPANY. I CERTIFY THAT THE INFORMATION I HAVE REPORTED WITH REGARD TO MY COVERAGE IS CORRECT. I FURTHER AUTHORIZE MOUNTAINEER VISION CENTER, PLLC TO RELEASE TO MY INSURANCE AND ITS AGENTS ANY INFORMATION RELATED TO THIS OR ANY RELATED CLAIM.

__________________________________________________________________________________________ PATIENT/GUARDIAN SIGNATURE DATE PATIENT/GUARDIAN PRINTED

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Reviewed By: _________ Date: ________