THANK YOU FOR SELECTING PRECISION EYECARE CENTERS TO PROVIDE YOUR VISION AND HEALTH NEEDS.
Please take a moment to complete our patient medical history questionnaire
Name (Dr / Mr / Ms / Miss / Mrs) Phone: Home Date of Birth Employer Occupation or Grade Level Spouse or Domestic Partner Last Medical Exam Medical Insurance Last Eye Exam Vision Insurance How did you hear about our office? PERSONAL EYE HISTORY
Do you wear glasses? If yes, for what purpose:
__________________________________________________________
SOCIAL HISTORY
This information is kept strictly confidential. However, you may discuss this directly with the doctor if you prefer.
Yes, I would prefer to discuss my Social History information directly with my doctor (please check)
If yes, type/amount/how long:________________________________
If yes, type/amount/how long:________________________________
If yes, type/amount/how long:________________________________
Hepatitis HIV Syphilis Other_____________________
To better understand your eyewear needs, please indicate what activities you are involved in (please circle):
Biking / Golf / Fishing / Snowboarding or Skiing / Hunting / Sewing or Knitting / Tennis / Baseball or Softball
Racquetball / Other: __________________________________________________________________________________
PERSONAL MEDICAL INFORMATION
Do you have any allergies to medications? No Yes
Explain:_________________________________________________________________________________________
List any medications you take (including contraceptives, aspirin, over the counter medications, and homeopathic remedies): ______________________________________________________________________________________
List any major injuries and surgeries you have had:______________________________________________________
Do you currently, or have you had problems in the following systems?
CONSTITUTIONAL EARS, NOSE, THROAT INTEGUMENTARY (skin) NEUROLOGICAL VASCULAR GASTROINTESTINAL ENDOCRINE LYMPHATIC/HEMATOLOGIC RESPIRATORY PSYCHIATRIC GENITOURINARY BONES/JOINTS/MUSCLES PREGNANT OR NURSING ALLERGIC/IMMUNOLOGIC FAMILY HISTORY
Please note any family history (parents, grandparents, siblings; living or deceased) for the following conditions:
DISEASE/CONDITION RELATIONSHIP TO YOU
Other: _______________________
If you answered yes to any of the above, please explain: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ASSIGNMENT AND RELEASE
I, the undersigned certify that I (or my dependent) have vision insurance coverage with_______________________ and medical insurance coverage with_________________________ and assign directly to El Camino Optometric Group all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all chargeswhether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
__________ History Reviewed No Changes__________ History Reviewed No Changes__________ History Reviewed No Changes
PROGRAMA FINAL III Curso Internacional sobre Obesidad en Español SAN ANTONIO, TEXAS 2009 TEMAS SELECTOS Avances en: Aspectos de Fisiología y Bioquímica Aplicados a la Clínica en el Manejo de la Obesidad Aspectos Genómico -Moleculares para Entender la Biología del Tejido Adiposo Estado del Arte 2009 RAUL A. BASTARRACHEA, M.D. Profesor Ti