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Welcome Hills Vision Studio

Dr. Vinal Patel, O.D.

PLEASE PRESENT ALL VISION AND MAJOR MEDICAL INFORMATION TO RECEPTIONIST

For Insurance Purposes:
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Patient's Name:

Last Name*

First Name*

Date of Birth*

Last 4 SS#

Address:

City:

Zip:

Cel#

Home#

Medical Insurance:

Email:

Note: It is now required we obtain an email address so we can upload your visit to the patient portal.
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Responsible Member:

First Name*

Last Name*

Date of Birth*

Last 4 SS#

Primary Language:

Special Needs:

Race

Ethnicity

Last PCP Visit:

PCP #

Last Eye Exam

Miscellaneous
List any previous surgeries with dates

Are you Pregnant?

Hobbies/Recreational Sports you enjoy
How many hours per day do you use a computer?

Do you wear glasses?

Are you interested in contact lenses?

Are you interested in refractive surgery?

Do you perform fine or close-up work?

Are you outdoors all or part of the time?

Do you have trouble reading signs when driving at night?

Are you sensitive in bright sunlight?

Are you bothered by glare from:

Overhead Lighting?
A computer screen?
Oncoming headlights at night?

Review of Systems
Do you currently have or have you ever had, any of the following problems or conditions?

Cardiovascular

Heart Disease

High Blood Pressure

High Cholesterol

Stroke

Vascular Disease

Ears/Nose/Mouth/Throat

Allergies

Sinus Congestion

Post Nasal Drip

Chronic Cough

Dry Mouth/Throat

Respiratory

Asthma

Chronic Bronchitis

Emphysema

Sleep Apnea

Gastrointestinal​​​​​​​

Constipation

Crohn’s Disease

Hepatitis A

Hepatitis B

Hepatitis C

Ulcer / Reflux

Genito-Urinary

Bladder / Genital / Kidney

Herpes Simplex

Prostate

Musculoskeletal

Joint / Muscle Pain

Osteo Arthritis

Rheumatoid Arthritis

Integumentary (skin)

Skin Cancer

Skin Disease

Herpes Zoster/Shingles

Neurological

Headaches

Migraines

Multiple Sclerosis

Gout

Seizures

Psychiatric

Anxiety / Depression

Endocrine​​​​​​​

Diabetes Type I

Diabetes Type II

Thyroid/Other Glands

Lymphatic – Hematologic

Anemia

Bleeding Problems

Allergic / Immunologic​​​​​​​

Eczema

Hives

Lupus

Organ transplant

Ocular History

(mark yes or no to each question)


Age-related macular degeneration


Amblyopia (Lazy Eye)


Vision Impaired - one eye


Vision Impaired - both eyes


Cataracts


Glaucoma


History of Refractive Surgery


Injury to the eye region


Keratoconus


Retinopathy


Strabismus (Crossed eyes)


Tear film insufficiency (dry eyes)


Other


Patient's Past Medical History

(mark yes or no to each question)


Acquired Immune Deficiency Syndrome (AIDS)


Arthritis


Asthma


Cancer


Chronic obstructive lung disease (COPD)


Diabetes mellitus


Emphysema
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Heart Disease
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Human immunodeficiency virus infection ( HIV)
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Hypercholesterolemia (high cholesterol)​​​​​​​
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Hypertensive disorder (hypertension)
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Seasonal Allergy


Thyroid dysfunction
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Mental Disorder
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Rheumatoid arthritis
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Family Health History

(mark yes or no to each entry. If yes, list which family member including mother, father, brother, sister, maternal/paternal, grandmother or maternal/paternal grandfather)


Amblyopia (Lazy eye)
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Blindness and/or vision impairment
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Cataract
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Macular Degeneration
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Glaucoma
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Retinal Disorder
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Strabismus (cross eyes)
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Arthritis
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Cancer
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Diabetes mellitus
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Hypertension (high blood pressure)
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Cardiovascular disease
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Stroke
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Social History

(check one for each question)
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Do you use recreational Drugs?
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Are you a:
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Tobacco Use​​​​​​​

(mark which one applies)
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Medication

List all CURRENT prescriptions, over-the-counter prescriptions, eye drops, and dosages for each.


Medication Allergies

List any allergies you may have and reactions.
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Pharmacy Name:


Telephone #:
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​​​​​​​​​​​​​​I, agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.


Date:
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