Welcome to Underwood Optical

Welcome to Underwood Optical

Patient Name:______Date of Birth:____ /____ /____

Address:______City:______State______Zip______

Telephone Number (Home)______(Cell)______(Work)______

Email Address______

Social Security Number______Occupation/Employer______

Sex: Male___ Female___ Marital Status:______Emergency Contact #______

Spouse or Parent

Race: ______Ethnicity: Hispanic or Latino or Not Hispanic or Latino

Name of Primary Doctor/Clinic:______Dateof last medical exam:____ / ____ /____

Please indicate your method of payment: Cash___ Check___ Credit Card___ Insurance___

PLEASE PRESENT ALL INSURANCE CARDS AND IDENIFICATION AT DESK

I consent to treatment as necessary or desirable to the care of the patient named above, including but not limited to medications or other studies that may be used by the attending optometrist, or qualified designate. Charges shown by statements are agreed to be correct and reasonable unless protested in writing within 30 days of billing date. In the event legal action should become necessary to collect an unpaid debt for optical services rendered to me or my family, I/we agree to pay reasonable attorney’s fees, collection costs, interest, or any other fees the court demes proper. I hereby authorize payment of medical insurance to Dr. Underwood, and authorize release of any medical information acquired in the course of my examination of treatment.

SIGNATURE:______Who is responsible for this bill?______

Smoking Status: Never___ Former___ Current___ Alcohol: None___ Occasional___ Social___

Major Injuries/Surgeries :______

Other Medical History: ______

Have you ever had any eye injuries? Yes / No Describe:______

Have you ever had any eye surgeries? Yes / No Describe: ______

Do you use any eye medication? Yes / No Describe:______

Date of your last Eye Exam?______Date of your last Physical Exam ?______

Have you ever been diagnosed with any of the following?

Cataracts: Yes / No Retinal Detachment: Yes / No

Glaucoma: Yes / No Crossed or Lazy Eye: Yes / No

Macular Degeneration: Yes/ No Eye turn strabismus: Yes / No

What is your primary vision concern today?______

R. Duke Underwood, OD & Underwood Optical Inc. Reserves the right to modify the privacy practices outlined in the notice. I acknowledge that I received a copy of R. Duke Underwood, OD & Underwood Optical, Inc. Notice of Privacy Practices.

Patient Name:______

Signature:______

Signature of Patient Representative:

______Date:______

(Required if the patient is a minor or an adult who is unable to sign the form)

***PLEASE TURN OVER AND COMPLETE THE OTHER SIDE***

Personal Medical History: Please check if any of the following applies to you past or present and list all medication taken below. If you have none of these conditions please check NONE.

Cardiovascular:
___High Blood Pressure
___Heart Disease
___Vascular Disease
___Stroke
___Cancer
___Other:______
___None / Constitutional:
___Cancer:______
___Fatigue Syndrome
___Developmental Disability
___Other:______
___None / Psychiatric:
___ADHD
___Depression
___Schizophrenia
___Anxiety
___Bipolar Disorder
___None
Neurological:
___Multiple Sclerosis
___Epilepsy / Seizure
___Cerebral Palsy
___Tumor
___Migraines
___Other:______
___None / Musculoskeletal:
___Arthritis
___Fibromyalgia
___Muscular Dystrophy
___Osteoarthritis
___Osteoporosis
___Other:______
___None / Integumentary:
___Eczema
___Rosacea
___Shingles
___Psoriasis
___Other: ______
___None
Hematological:
___Anemia
___Leukemia
___Ulcer
___Hypercholesterolemia
___Other:______
___None / Gastrointestinal:
___Cohn’s Disease
___Colitis
___Ulcer
___Acid Reflux
___Other:______
___None / Ear/Nose/Throat:
___Hearing Loss
___Sinusitis
___Dry Mouth
___Other:______
___None
Endocrine:
___Type 2 Diabetes
___Type 1 Diabetes
___Thyroid Problem
___Hormonal Dysfunction
___Other:______
___None / Respiratory:
___Asthma
___Bronchitis
___Emphysema
___COPD
___Sleep Apnea
___Other:______
___None / Medication Allergies: (Please List)
None_____
Environmental Allergies:

Please list any medications you are currently taking or ask our staff to make a copy of tour medication list. Include all medications, vitamins, herbs, supplements, and over the counter medications.

1.______6.______

2.______7.______

3.______8.______

4.______9.______

5.______10.______

Family History: Has anyone in your immediate family (grandparents, parents, siblings and children) been diagnoses with:

Disease/Condition Relationship Relationship

Lupus Yes/No ______Blindness Yes/No ______

High Blood Pressure Yes/No ______Cataracts Yes/No ______

Diabetes Yes/No ______Glaucoma Yes/No ______

Heart Disease Yes/No ______Crossed Eyes Yes/No ______

Thyroid Disease Yes/No ______Macular Degeneration Yes/No ______

Cancer Yes/No ______Retinal Detachment Yes/No ______