TSO

PATIENT INFORMATION
Date:     
SS/HIC/Patient ID:
Patient Legal Name:     
Address:
City:
State:
Zip:
Email:
Height:  Feet  Inches
Weight:  Lbs
Sex: M F Age:  Birthdate:  
Married Widowed Single Minor
Separated Divorced
Occupation:
Patient employer/school:
Patient employer/school Address:
Employer/school Phone:
Spouse's Legal Name :
Birthdate:    
SS#:
Spouse's employer:
Whom may we thank for referring you?
INSURANCE
Who is the primary insured(name on card):
Relationship to patient:
Insurance Co.:
Insurance ID#:
Group #:
is patient covered by additional insurance?
YesNo
Subscriber's Name (name on card):
Birthdate:  
SS#:
Relationship to patient:
Insurance Co.:
Insurance ID#:
Group #:
I certify that I. and/or my dependent(s), have insurance coverage with and assign directly to Dr. all insurance benefits, if any. Otherwise payable to me for service rendered. I understand that i am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above named doctor may use my health care information and may disclose such information to the above named insurance Company(ies)and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
Signature of Patient,Parent,Guardian or Personal- Representative: 
Please enter name of Patient,Parent,Guardian or Personal Representative: 
Relationship to patient:
Date:    
PHONE NUMBERS
Home: Cell: work: Spouse's Phone: Ext:
Best time and place to reach you   
IN CASE OF EMERGENCY,CONTACT(Specify someone who does not live in your household)
Emergency Contact:   Name: Relationship:
Home:   Cell:
PREFERRED LANGUAGE:  ENGLISH SPANISH
RACE:  American Indian or Alaska Native Asian Black or African American Hispanic
Native Hawaian/ Other Pacific Island White
ETHNICITY:  Hispanic or Latino Native Hawaian/Other Pacific Island Not Hispanic or Latino
COMMUNICATION PREFERENCE:E-mail Postal Telephone
HEALTH HISTORY
Place a mark on "Yes" or "No" to indicate if you have any of the following. Also place a mark to indicate if a blood relative has had any of the following problems.
You
Blood Relative
You
Blood Relative
AIDS/HIVYesNoYesNo MOOD DISORDERYesNoYesNo
ARTHRITISYesNoYesNo MULTIPLE SCLEROSISYesNoYesNo
ASTHMAYesNoYesNo PARKINSON'S DISEASEYesNoYesNo
ATTENTION DISORDERYesNoYesNo SHINGLESYesNoYesNo
AUTISMYesNoYesNo SKIN DISORDERYesNoYesNo
BLOOD DISORDERYesNoYesNo STROKE YesNoYesNo
CANCER YesNoYesNo THYROID DISORDERYesNoYesNo
CROHN'S DISEASEYesNoYesNo TUBERCULOSISYesNoYesNo
DIABETESYesNoYesNo
EPILEPSYYesNoYesNo
GENITOURINARY DISORDERYesNoYesNo
HEADACHESYesNoYesNo
HEART DISEASEYesNoYesNo
HYPERTENSIONYesNoYesNo
HEPATITIS/ LIVER DISORDERYesNoYesNo
KIDNEY DISEASE/ STONESYesNoYesNo
LUNG DISEASEYesNoYesNo
LUPUSYesNoYesNo
MENOPAUSEYesNoYesNo
MIGRAINE HEADACHESYesNoYesNo
 
EYE HEALTH HISTORY
Place a mark on "Yes" or "No" to indicate if you have any of the following.
You
Blood Relative
You
Blood Relative
GLAUCOMAYesNoYesNo POOR COLOR VISIONYesNoYesNo
MACULAR DEGENERATIONYesNoYesNo RETINAL DISEASEYesNoYesNo
DRY EYESYesNoYesNo RETINAL DETACHMENTYesNoYesNo
LAZY EYEYesNoYesNo CATARACTSYesNoYesNo
POOR NIGHT VISIONYesNoYesNo EYE INJURYYesNoYesNo
FLOATERS/ FLASHES/ SPOTSYesNoYesNo HALOS/ GLARE YesNoYesNo
 
MEDICATIONS
List any medications you are currently taking including eye drops:
Pharmacy Name :
Phone :
NAME OF PRIMARY PHYSICIAN :
ADDRESS :
PHONE NUMBER :
FAX NUMBER :
 
ALLERGIES
List your allergies to medications or any other substances:
Do you smoke?YesNo
Are you pregnant? YesNo
Alcohol use?YesNo
 
 * Security Code :