Welcome to the office of Thomas J. Moomaw, OD

IMPORTANT: This questionnaire is to be reviewed at each appointment. Please answer all questions. All information will be kept confidential. Thank you for choosing our office for your eyecare needs.

Patient InformationToday’s date ______Email ______

Name Birthdate ______

Address City ,OH Zip

Phone #s - Home Cell Work ______

Which phone number would you prefer that we contact you? home/ cell / work

Spouse Patient’s Employer/ School

Emergency contact name & phone number ______

Date of last eye exam Dilated? Yes/No Referred by ______

Primary vision coverage/ID____ Secondary coverage

Medical insurance coverage ______

Family physician Phone #

Specialist Phone #

Medical Information – please circle all conditions that you are currently being treated for:

Constitutional / Recent weight change / Fever / Fatigue / Thyroid / Heart condition
Diabetes / High blood pressure / Allergies / Parkinson’s
Respiratory / Tuberculosis / Chronic cough / Shortness of breath / Wheezing
Ear/Nose / Earaches/ drainage / Chronic sinus problems / Sore throat
Hematologic / Anemia / Bleeding/bruising / Slow to heal after cuts
Neurological / Numbness/ tingling sensation / Paralysis / Headaches / Light headed/ dizzy / Convulsions/ seizures / Tremors/ head injury
Psychiatric / Memory loss/ confusion / Depression / Nervousness / Insomnia

Eye conditions – please circle all conditions that you have been treated for:

Eye surgery / Eye injury / Severe pain / Eye strain / Infections
Tired eyes / Dryness/redness / Sensitivity to light or glare / Floaters or spots / Sandy or gritty
Foreign body sensation / Loss of vision / Distorted vision / Lazy or cross eye / Medical treatment
Double vision / Halos around lights / Reactions to eye drops / Blurred vision / Drooping eyelid
Eye disease / Burn, itchy, excess tearing / Fluctuation vision / Loss of side vision / Cataracts
Glaucoma / Blindness / Retinal detachment / Other:

Medications – please list all of your medications including dosage and the condition it is treating

Allergies to medications? yes/noExplain reaction:

Do you currently wear glasses? yes/no Contacts? yes/no What kind of contacts?

Are you interested in refractive surgery? Yes/no

Family History

High blood pressure- yes/no Relation ______Macular degeneration- yes/no Relation ______

Diabetes - yes/no Relation ______Retinal detachment - yes/no Relation ______

Glaucoma - yes/no Relation ______Cataracts - yes/no Relation ______

List the names and phone numbers of two people that you give consent/permission for our office to give test results or medical information to:

Name ______Phone # ______

Name ______Phone # ______

Carefully read the following:

  1. It is my responsibility to provide current and accurate insurance information.
  2. I am responsible for all charges not covered by my primary insurance, including all services deemed necessary by the Doctor.
  3. Payment for professional services is required at the time the service is rendered.
  4. If ophthalmic materials are prescribed, a co-payment and/or deposit is required before an order will be placed and the balance is to be paid in full at the time of dispensing unless other arrangements are made ahead of time.

Authorization

I certify that I have read and understand the Notice of Privacy Practices and the above questions have been accurately answered. I authorize Thomas J. Moomaw, OD to release any information, including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eyecare to third payers and/or health practitioners. I authorize and request my insurance company to pay directly to Thomas J. Moomaw, OD. I understand that my eyecare insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Relationship to patient ______

X______Date ______

Signature of patient (or parent/guardian if a minor)

OFFICE USE ONLY

I attempted to obtain the patient’s signature in acknowledgement on the Notice of Privacy Practices Acknowledgement but was unable to do so as documented below:

Date ______Initials ______Reason ______

Doctor use only

Reviewed by ______( ) No changes Date ______

Reviewed by ______( ) No changes Date ______

Reviewed by ______( ) No changes Date ______

Reviewed by ______( ) No changes Date ______

Reviewed by ______( ) No changes Date ______

Reviewed by ______( ) No changes Date ______