somerseyecenter.com-PATIENT-INFORMATION-FORM.

SOMERS EYE CENTER

PATIENT HEALTH HISTORY
Name

First NameMiddle NameLast Name
DATE OF BIRTH:

MonthDayYear
Date
SOCIAL SECURITY #:
MAILING ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GENDER:

MaleFemaleOther
MARITAL STATUS:

SINGLEMARRIEDWIDOWEDDIVORCED
PREFERRED LANGUAGE:
RACE/ETHNICITY:
EMPLOYER:
CONTACT INFO:
CELL #:
Please enter a valid phone number.
HOME #:
Please enter a valid phone number.
WORK #:
Please enter a valid phone number.
EMAIL ADDRESS:
example@example.com
ALTERNATIVE CONTACT PERSON:
NAME
RELATIONSHIP
CELL #
Please enter a valid phone number.
HOME #
Please enter a valid phone number.
WORK #
Please enter a valid phone number.
EMAIL
example@example.com
PRIMARY INSURANCE CARRIER:
INSURANCE ID:
GROUP #:
POLICY HOLDER NAME (if not yourself):
RELATIONSHIP:
DATE OF BIRTH:

MonthDayYear
Date
SOCIAL SECURITY #:
RESPONSIBLE PARTY NAME (if not yourself):
NAME:
ADDRESS:
PHONE #:
Please enter a valid phone number.
DOB

MonthDayYear
Date
PRIMARY CARE PHYSICIAN NAME:
PRACTICE NAME:
PRIMARY CARE PHYSICIAN'S NAME
PHONE #:
Please enter a valid phone number.
FAX #:
PHARMACY OF CHOICE:
LOCATION:
PHONE #:
Please enter a valid phone number.
FAX #:
PATIENT SIGNATURE:

Type your full name for your digital signature Clear
DATE:

MonthDayYear
Date
PATIENT HEALTH HISTORY
REASON FOR YOUR VISIT TODAY:
DURATION OF SYMPTOMS/ PROBLEMS:
Please list anything that you are currently using in your eyes (drops, ointments, saline, etc.):

EYE HISTORY (PLEASE INDICATE ANY THAT APPLY):

	CURRENT	PAST	NEVER
GLASSES:
CONTACT LENSES:

	RIGHT	LEFT	BOTH	NEVER
CATARACTS
CATARACT SURGERY
RETINAL DISEASE
RETINAL SURGERY
RETINAL DETACHMENT
REFRACTIVE SURGERY
LASER SURGERY
CORNEAL TRANSPLANT

How did you hear about us? Did someone specific refer you to us that we could thank with your permission?
REFERRED BY:

VACCINATIONS /IMMUNIZATIONS (PLEASE CIRCLE ALL THAT APPLY):

	YES	NO	UNSURE
PNEUMOCOCCAL VACCINATION (PNEUMONIA SHOT):
INFLUENZA IMMUNIZATION (FLU SHOT) within the last 1 year:
COVID VACCINATION:

PAST MEDICAL HISTORY :

ARTHRITISASTHMA/LUNG DISEASEBLINDNESSBLOOD DISORDER CANCERDIABETESDIGESTIVE DISORDERGLAUCOMAHARD OF HEARINGINFECTIOUS DISEASEKIDNEY DISEASEHEART DISEASEHIGH BLOOD PRESSUREHIGH CHOLESTEROLLIVER DISEASEMACULAR DEGENERATIONMIGRAINE/ HEADACHESPSYCHIATRIC DISORDERSEIZURESSEASONAL ALLERGIESSKIN DISEASESTROKENONE
ANY OTHER HEALTH PROBLEMS/DIAGNOSES NOT LISTED ABOVE
PLEASE LIST ALL SURGERIES AND HOSPITALIZATIONS WITH DATES (if known):
CURRENT MEDICATIONS:

Please see the list I will bring in to my appointmentI don’t know my medicationsI don’t take ANY medications
Please list all medications
ALLERGIES TO MEDICATIONS

Please see the list I will bring in to my appointmentI don’t know my medicationsI don’t take ANY medications
Please list all allergies

FAMILY MEDICAL HISTORY:

PLEASE INDICATE BY CHECKING THE BOX WHICH FAMILY MEMBER HAD THE MEDICAL CONDITION(S):

LEGEND
M - MOTHER	GM - GRANDMOTHER	SS - SISTER	A - AUNT	D - DAUGHTER
F - FATHER	GF - GRANDFATHER	B - BROTHER	U - UNCLE	S - SON

	M	F	GM	GF	SS	B	A	U	S	D
ARTHRITIS
ALLERGIES
BLINDNESS
DIABETES
HEART DISEASE
MACULAR DEGENERATION
ASTHMA
CANCER
GLAUCOMA
HIGH BLOOD PRESSURE
STROKE

OTHER MEDICAL CONDITIONS IN FAMILY MEMBERS NOT LISTED ABOVE:
NO ONE in my family has any medical problems
UNKNOWN (I don’t know of any)UNKNOWN (I was adopted)
SOCIAL HISTORY

SINGLEMARRIEDDIVORCEDWIDOWED
TOBACCO USE:

YESNEVERFORMER
FORMER (DATE QUIT)

MonthDayYear
GREAT job quitting!
(DAILY AMOUNT (TYPE: cigarettes, pipi, vape, chewing tobacco, etc.)
Please note that Drs. Somers and Blacklock strongly recommend not smoking, as it causes damage throughout your body, including to your eyes!
ALCOHOL INTAKE

OCCASIONALSOCIAL 1-2 DRINKS A DAY3-4 DRINKS A DAYOTHER DAILY AMOUNT
OCCUPATION:

WORKINGSTUDENTRETIREDDISABLEDUNEMPLOYED
if working, my occupation is
FALL RISK: Do you feel you are at risk to fall, or have you fallen in the last year?

YESNO
THANK YOU FOR COMPLETING THESE FORMS AND
HELPING US PROVIDE YOU WITH THE BEST CARE POSSIBLE!
PATIENT SIGNATURE:

Clear
Date

MonthDayYear
Date
SOMERS EYE CENTER HIPAA COMPLIANCE AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH CARE INFORMATION
By signing this form I authorize the use and disclosure of my health information as described in the Notices of Privacy Practices. I have been given a copy of the Notice of Privacy Practices to read and keep if I desire.

To revoke this authorization, I must do so in writing and send it to:

SOMERS EYE CENTER

Attention: HIPAA Compliance Officer

2790 Clay Edwards Dr. Ste 1240

North Kansas City, MO 64116

I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the federal Privacy Standards.
I authorize Somers Eye Center to:

Speak directly to meMay leave a messageMay disclose information to the following person(s)
Phone Number
Please enter a valid phone number.
NAME
RELATIONSHIP
PHONE NUMBER
Please enter a valid phone number.
NAME
RELATIONSHIP
PHONE NUMBER
Please enter a valid phone number.
PATIENT SIGNATURE:

Clear
Date

MonthDayYear
Date
Should be Empty:

SOMERS EYE CENTER

PATIENT HEALTH HISTORY

SOMERS EYE CENTER HIPAA COMPLIANCE AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH CARE INFORMATION