Welcome to JELC Thank you for choosing us! DEMOGRAPHICS Patient Name Eye Care Physician Preferred Name Male Address Female D.O.B. / / Age _______ Email City, State Zip Home/Cell # Employer Occupation Emergency Contact Phone # Health Conditions: □ Pregnant/Breast Feeding □ Diabetes (within last 6 months) □ Lupus/MS Eye History: ____ □ Rheumatoid Arthritis □ HIV □ Keratoconus □ Amblyopia (Lazy Eye) □ Cataracts □ Glaucoma □ Herpes Zoster/Simplex □ Trauma □ Other ______________________________________________________ Current Medications: □ Corneal Ulcer □ Retinal Detachment Drug Allergies: Presently Wearing: □ Glasses □ Soft Contacts □ Gas Permeable Contacts □ No Correction Years of Contact Lens Wear: When Contact Lenses Last Worn: Interested in Refractive Surgery Because: □ Contact Lens Intolerant □ Occupational Needs □ Active Lifestyle □ Freedom From Glasses How Did You Hear About Us? □ □ □ □ □ □ □ □ □ Eye Care Physician: Website □ Facebook Previous Patient: Mailer Radio Station: Newspaper Television Station: Yellow Pages Other Source: Patient Signature: (limit one person for referral gift) Date: (By signing, I hereby authorize JELC and its employees to release any information concerning my care to any other physician associated with my care.) Rev 08/09 Answer the following questions by circling the number in the box that best represents your answer. HAVE YOU EXPERIENCED ANY OF THE FOLLOWING DURING THE LAST WEEK: ALL OF THE TIME 1) Eyes that are sensitive to light? 2) Eyes that feel gritty? 3) Painful or sore eyes? 4) Blurred vision? 5) Poor vision? 4 4 4 4 4 MOST OF HALF OF THE TIME THE TIME 3 3 3 3 3 2 2 2 2 2 SOME OF THE TIME 1 1 1 1 1 NONE OF THE TIME 0 0 0 0 0 HAVE PROBLEMS WITH YOUR EYE LIMITED YOU IN PERFORMING ANY OF THE FOLLOWING DURING THE LAST WEEK: ALL OF THE TIME 6) Reading? 7) Driving at night? 8) Working with a computer? 9) Watching TV? 4 4 4 4 MOST OF HALF OF THE TIME THE TIME 3 3 3 3 2 2 2 2 SOME OF THE TIME 1 1 1 1 NONE OF THE TIME 0 0 0 0 HAVE YOUR EYES FELT UNCOMFORTABLE IN ANY OF THE FOLLOWING SITUATIONS DURING THE LAST WEEK: ALL OF THE TIME 10) Windy conditions? 11) Places or areas with low humidity? 12) Areas that are air conditioned? 4 4 4 MOST OF HALF OF THE TIME THE TIME 3 3 3 2 2 2 SOME OF THE TIME 1 1 1 NONE OF THE TIME 0 0 0 ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES 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 have been given the opportunity to read and understand the Notice of Privacy Practices for the Joplin Eye Laser Center. I understand that the policy can be changed at any time, but if changed I will be notified and given a copy of the new policy. I also understand that if I have any questions with regard to the policy that I can speak to the Privacy Officer of the Joplin Eye Laser Center. Patient Name: Signature: Date: If not signed by patient, relationship to patient: Date: OFFICE USE ONLY I attempted to obtain the patient’s signature in acknowledgement on this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below: