PATIENT INFORMATION ACKNOWLEDGEMENT OF RECIEPT OF PRIVACY PRACTICES Mr. Mrs. Ms. Today’s Date: ___________ Signing this document signifies that you have Name: _____________________________ M/F received a copy of our Address: _______________________________ Notice of Privacy Practices *In the course of providing service to you, we ______________________________________ create, receive and store health information that City: ___________________ State: _________ identifies you. It is often necessary to use and Zip Code: _______________ disclose this health information in order to treat Hm Phone: ( ) ____________________ you, to obtain payment for our services, and to Cell Phone: ( ) ____________________ conduct healthcare operations involving our office. The notice of Privacy Practices you have been E-Mail:_____________________________ given describes these uses and disclosers in detail. Birth Date: ______________ *When you sign this consent document, you Social Sec#:______________ signify that you agree that we can and will use and Employer: _______________________________ disclose your health information to treat you, to Occupation: ______________________________ obtain payment for our services and to perform Name of Spouse/Parent: ____________________ health care operations you can revoke this consent How did you hear about us? Local Ppr/ Facebook in writing at any time. Unless we have already treated you, sought payment for our services or Website/ Online Search/Other ____________________________________ performed health care operations in reliance upon OUR PAYMENT POLICY our ability to use or disclose your health information in accordance with this consent. I acknowledge that I have received the Notice of privacy practices from Dr.Melody O. Quenzer at Eye Q Optometry. 1. Payment in full is due at time of services 2. A $30 service charge on all returned checks 3. Insurance Policy—Regardless of any insurance coverage, the total balance due is the legal X: ___________________________ Date________ If signing as a personal representative of the patient, responsibility of the patient. Payment not received within 60 days will be the describe the relationship to patient and the source of authority to sign this form: patients responsibility. X: _______________________________________ 4. I have read and understand the above: I give permission to release my information to: (Please Sign):_______________________________ _________________________________________ _________________________________________ INSURANCE INFORMATION MEDICARE AUTHORIZATION Who is responsible for the account? _______________________________________ Relationship to Patient: ____________________ Medical Insurance Co: _____________________ Vision Ins. Co: ___________________________ Subscriber’s Name: ________________________ Subscriber’s DOB: ___________ Relationship to Patient: _____________________ I request that payment of authorized Medicare benefits be made to me or on my behalf to Dr. Melody O. Quenzer for any or all services. To the extent permitted by law, I authorize any holder of medical or other information about me to release to Dr. Melody Quenzer any information needed to determine these benefits for related services. Signature of Beneficiary, Guardian/Representative _______________________________Date:___________ Print name of Beneficiary/representative & Relationship: Medical History Last Eye Exam: ______________ Last Medical Exam: ___________ Do you have any allergies to medications? ____No ____Yes If yes, explain: _________________________________________________________________ Please attach list of any medications you take including oral contraceptives, aspirin, over the counter medications and home remedies: ____________________________________________ _____________________________________________________________________________ List all major injuries, surgeries and or hospitalizations you’ve had: _______________________ ______________________________________________________________________________ List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections or eye injuries:____________________ _____________________________________________________________________________________________ Review of Systems: Do you currently, or have you ever had any problems in the following areas: SYSTEM YES NO ? CONSTITUTIONAL Fever, Weight loss/gain ____ ____ ____ INTEGUMENTARY (skin) ____ ____ ____ NEUROLOGICAL Headaches ____ ____ ____ Migraines ____ ____ ____ Seizures ____ ____ ____ EYES Loss of Vision ____ ____ ____ Blurred Vision ____ ____ ____ Distorted Vision/Halos ____ ____ ____ Loss of Side Vision ____ ____ ____ Double Vision ____ ____ ____ Dryness ____ ____ ____ Mucous Discharge ____ ____ ____ Redness ____ ____ ____ Sandy/gritty feeling ____ ____ ____ Itching ____ ____ ____ Burning ____ ____ ____ Foreign Body Sensation ____ ____ ____ Excess Tearing/Watering ____ ____ ____ Glare/Light Sensitive ____ ____ ____ Eye pain/Soreness ____ ____ ____ Chronic Eye/lid Infection ____ ____ ____ Sties/Chalazion ____ ____ ____ Flashes/Floaters ____ ____ ____ Tired Eyes ____ ____ ____ ENDOCRINE Thyroid/Other Glands ____ ____ ____ SYSTEM YES NO ? EARS, NOSE, MOUTH, THROAT Allergies/Hay Fever ____ ____ ____ Sinus Congestion ____ ____ ____ Runny Nose ____ ____ ____ Post-Nasal Drip ____ ____ ____ Chronic Cough ____ ____ ____ Dry Throat/Mouth ____ ____ ____ RESPIRATORY Asthma ____ ____ ____ Chronic Bronchitis ____ ____ ____ Emphysema ____ ____ ____ VASCULAR/CARDIOVASCULAR Diabetes ____ ____ ____ Heart Pain ____ ____ ____ High Blood Pressure ____ ____ ____ Vascular Disease ____ ____ ____ GASTROINTESTINAL Diarrhea ____ ____ ____ Constipation ____ ____ ____ GENITOURINARY Genitals/Kidney/Bladder ____ ____ ____ BONES/JOINTS/MUSCLES Rheumatoid Arthritis ____ ____ ____ Muscle Pain ____ ____ ____ Joint Pain ____ ____ ____ LYMPHATIC/HEMTOLOGIC Anemia ____ ____ ____ Bleeding Problems ____ ____ ____ ALLERGIC/IMMUNOLOGIC____ ____ ____ PSYCHIATRIC ____ ____ ____ If you answered YES to any of the above or have a condition not listed, please explain and list medications:__________________________________________________________________________ ____________________________________________________________________________________ Social History This information is kept strictly confidential. However, you may discuss this portion directly with your doctor if you prefer. ____ Yes I would prefer to discuss my social history information directly with my doctor. Do you drive? ____No ____ Yes If yes, do you have visual difficulty when you drive? ____No ____ Yes If yes, describe: ____________________________________________________________ __________________________________________________________________________ Do you use tobacco products? ____No ____ Yes If yes, type/amount/how long: ________________________________________________________________ Do you drink alcohol? ____ No ____ Yes If yes, type/amount/how long: ________________________________________________________________ Do you use illegal drugs? ____No ____Yes if yes, type/amount/how long: ________________________________________________________________ Have you ever been exposed to or infected with: ____Gonorrhea ____ Hepatitis ____ HIV ____ Syphilis Family History DISEASE/CONDITION YES NO ? RELATIONSHIP TO YOU Blindness ____ ____ ____ ____________________________________ Cataract ____ ____ ____ ____________________________________ Crossed Eyes ____ ____ ____ ____________________________________ Glaucoma ____ ____ ____ ____________________________________ Macular Degeneration ____ ____ ____ ____________________________________ Retinal Detachment ____ ____ ____ ____________________________________ Arthritis ____ ____ ____ ____________________________________ Cancer ____ ____ ____ ____________________________________ Diabetes ____ ____ ____ ____________________________________ Heart Disease ____ ____ ____ ____________________________________ High Blood Pressure ____ ____ ____ ____________________________________ Kidney Disease ____ ____ ____ ____________________________________ Lupus ____ ____ ____ ____________________________________ Thyroid Disease ____ ____ ____ ____________________________________ Other: _______________ ____ ____ ____ ____________________________________ and/or Disease Doctor Signature: __________________________________ Date: __________________