New Patient Form - HFT Eye Care and Surgery

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New Patient Information

Name *

First

Last

Email

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home # *

Cell #

Work #

Date of Birth *

Age *

Family Physician *

Referring Physician: *

Local Pharmacy: *

Local Pharmacy Address:

Address Line 1

Address Line 2

City

State

Zip Code

Mail Order Pharmacy:

Emergency Contact: *

Phone *

Gender *

Male
Female

Race *

White
Asian
Black/African American‎
Spanish/Hispanic Origin
American Indian‎
Native Hawaiian/Other Pacific Islander‎
Other

Preferred Language *

Is patient enrolled in Hospice? *

Yes
No

If yes, Medicare ID #:

Primary Medical Insurance

Subscriber

ID No.

DOB

Group ID #

If seen by us for a worker's compensation injury:

what Name use:

Company

HR Contact

Phone

In order to comply with federal regulations regarding your privacy in our office, we ask that you complete the following questions:

How can we communicate APPOINTMENT information?

Home Phone
Cell Phone
Work Phone
With a Specific Person
US Mail
E-mail

How can we communicate MEDICAL information?

Home Phone
Cell Phone
Work Phone
With a Specific Person
US Mail
E-mail

Please provide the name and relationship of the specific person(s) with whom we may share patient information (medical, billing, and appointments) about you. This information will only expire when requested by the patient.

Name

First

Last

Relationship

Phone

Name

First

Last

Relationship

Phone

Name

First

Last

Relationship

Phone

Allergies to Medications? *

Height

Weight

Last Hemoglobin AIC

Employer

Occupation

Job Physical Function (i.e. lifting, bending, etc.)

Reason for Today's Visit *

Cataracts
Dry Eyes
Driving Difficulty (day/night)‎
Diabetic Exam‎
Flashes
Decreased Vision‎
Increased Vision‎
Floaters
Other

Would you like to be checked for a new eyeglass prescription today? *

Yes
No

Is your current problem injury related? *

Yes
No

If yes, date of injury:

Cause of Injury

Work Accident
Home Accident
Auto Accident
Sports Related Activity
Other

History of Present Problems/Illness (please describe your current problem)

Medical History (please check yes or no)

Heart Disease *

Yes
No

Cancer *

Yes
No

If yes, what type?

Mitral Valve Prolapse *

Yes
No

Rheumatoid Arthritis/Lupus *

Yes
No

Problem with Anestheia *

Yes
No

Ulcers/Stomach Problems *

Yes
No

Hemophilia/Bleeding Problems/Anemia *

Yes
No

Nervous/Mental Disorder/Depression *

Yes
No

Unusual Childhood Disease (measles, mumps, etc.) *

Yes
No

Blood Clot/DVT/Pulmonary Emulsion *

Yes
No

Diabetes *

Yes
No

Thyroid Disease *

Yes
No

High Blood Pressure *

Yes
No

Kidney Disease *

Yes
No

Hepatitis/Liver Disease *

Yes
No

HIV/AIDS *

Yes
No

Epilepsy/Seizures *

Yes
No

Cholesterol *

Yes
No

Venereal Disease *

Yes
No

Asthma/Respiratory Disease/TB *

Yes
No

Other:

Past Medical Surgical History (list types of surgery)

Past Eye Problems/Diseases

Past Eye Surgical History (list types of surgery)

Family Eye History (check all that apply)

Glaucoma‎
Diabetes
Macular Degeneration
Corneal Problems‎
Cataract‎
Adopted
Unknown

Do you drive?

Yes
No

If so;

Daytime only
Both day and nighttime driving

Social History

Married
Single
Divorced
Widow
Domestic Partner‎
Civil Union
Lives Alone

Alcohol Use

1-2 Drinks/Day‎
1-2 Drinks/Week‎
3+ Drinks/Day‎
Rarely Drinks‎
Never Drinks

Tobacco Use

Current Smoker‎
Chew/snuff
Former Smoker
Never Smoked

If you smoke, for how many years and how many packs per day?

Please list recreational drug use:

THE ABOVE INFORMATION IS CORRECT AND WAS FILLED OUT TO THE BEST OF MY ABILITY:

Electronic signature (type name) *

(Parent signature if patient is a minor)

Date *

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Give Heimer, Fiore, Turco Eye Care and Surgery a call today and talk to the experts in eye and cataract treatments.

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(+1) 814-234-1002

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1700 Old Gatesburg Road, Suite 300, State College, PA 16803

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