Jolly Good Eye Care, PLLC

Jolly Good Eye Care, PLLC
Patient Information and Medical History Form and Consent
Name *

First Name Last Name
Birthdate *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Sex
Please list Parent/ Guardian Name, if patient is a minor

First Name Last Name
Please provide BOTH your Vision and Medical Insurance to better assist you.
Vision Insurance Name *
Vision insurance ID # *
If you don't know, enter "IDK"
Policy Holder Name
Policy Holder Date of Birth

Month Day Year
Date
Medical Health Insurance Name *
Medical Health Insurance ID # *
If you don't know, enter "IDK"
General Medical History
Primary Physician
Date Of Last Physical Exam

Check any condition that apply

	You	Mom	Dad	Sibling	Grandparent
Hypertension
Thyroid
Cardiovascular
Cancer
Diabetes

If YOU are diabetic, when were you diagnosed and last A1C Level
List any other medical conditions you have had
List all Medication/ Vitamins you are currently taking *
Type "None" if not taking any meds
Please list any drug allergies *
Type "None" if not applicable
Review of Systems: Please list any problems you are having anywhere, from head to toe.
General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain)
Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, sleep apnea, hearing problems)
Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs)
Respiratory (e.g., chronic cough, shortness of breath, wheezing)
Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge, menstrual changes, impotence)
Gastrointestinal (e.g., constipation, diarrhea, gastric reflux (GERD), jaundice, nausea, vomiting)
Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination)
Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements)
Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration)
Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, dementia, speech problems)
Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive)
Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising)
Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes)
Ocular History
Last Eye Exam

Check any conditions that apply

	You	Mom	Dad	Sibling	Grandparent
Glaucoma
Macular Degeneration
Retinal Problem
Cataracts
Lazy Eye/ Eye Turn

List Any Vision Complaints *

None Blurred distance vision Blurred near vision Eye strain Double vision Losing your place when reading Itchy Dry Redness Pain/ Light sensitivity Flashes of light Floaters Watery eyes Other
***We at Jolly Good Eye Care are required by law to maintain the privacy of
and provide individuals with the Notice of our legal duties and privacy
practices with respect to protected health information, which can be viewed on our website. If you would like a copy of the Notice, please ask.***
By signing below, I acknowledge that all the above information is true. I hereby acknowledge that I have reviewed the HIPAA Notice of Privacy Practice document.

Clear
Signature of Patient or Guardian *
You can sign electronically by typing your full name
Date *

Month Day Year
Date
Should be Empty: