Welcome to Bynum Eye Care, P.A.

Patient Information

Patient Name

Address

CIty

State

Zip

Home Phone

Work Phone

Cell Phone

Preferred Contact Method

Home Work Cell

Email address

Date of Birth

Age

Marital Status

Gender

Male Female

Social Security Number

Driver License Number

Primary Language

Race

Any Special Needs?

Wheelchair

Hearing Impaired

Translator

Other

Special Needs (Other)

Occupation

Employer

Emergency Contact

Relationship

Phone

What is the state in which you were born?

Mother's Maiden Name

How did you hear about our office?

Website

Insurance List

Search Engine

Yellow Pages

Billboard

Referred by

Insurance Information

Do you have Vision Insurance?

Yes No

Name of Vision Insurance Provider

Subscriber Name

Subscriber Date of Birth

Subscriber ID

Subscriber Group Number

Do you have Medical Insurance

Yes No

Name of Medical Insurance Provider

Subscriber Name

Subscriber Date of Birth

Subscriber ID

Subscriber Group Number

If not covered by insurance, who is the responsible party?

Responsible Party Address

Responsible Party Phone

Do you participate in a Flex Spending Account?

Yes No

Primary Health History

Name of Primary Care Physician

Phone Number

Name of Optometrist / Ophthalmologist

Phone Number

Are you allergic to any medication?

Yes No

Please list medication allergies

What is the main reason for your visit today?

Do you wear...

Glasses

Contacts

Sunglasses

Brand Name of Contacts

Type of Contacts

Soft Rigid Other

Do you sleep in contacts

Yes No Sometimes

How often do you change your contacts

Daily Weekly Bi-weekly Monthly Yearly Other

Please specify timeframe

What brand of solution do you use on your contacts?

Average time spent on electronics per day?

Eye History

In what year did you have Lasik / RK?

In what year did you have Lid Surgery?

In what year did you have Cataract Surgery?

Health History

Constitutional

Developmental Delay

Weight Loss / Weight Gain

Fever

Fatigue

Trauma

Other

Constitutional Other

Respiratory

Asthma

Bronchitis

Emphysema

Other

Respiratory Other

Gastrointestinal

Ulcer

Colitis

Digestive

Other

Gastrointestinal Other

Genitourinary

Urinary Tract Infection

Kidney Ailments

STD: Herpes, Chlamydia, HIV

Other

Genitourinary Other

Musculoskeletal

Fibromyalgia

Osteoarthritis

Muscular Dystrophy

Other

Musculoskeletal Other

Integumentary

Eczema

Rosacea

Psoriasis

Other

Integumentary Other

Neurological

Multiple Sclerosis

Epilepsy

Other

Neurological Other

Psychiatric

Depression

Panic Disorder

Anxiety

Schizophrenia

Other

Psychiatric Other

Vascular / Cardiovascular

High / Low Blood Pressure

Stroke / Heart Problems

Other

Vascular / Cardiovascular Other

Endocrine

Type 1 / Type 2 Diabetic

Thyroid Low / High

Option

Endocrine Other

Blood / Lymphatic

Anemia

Leukemia

Other

Blood / Lymphatic Other

Immunologic

Rheumatoid Arthritis

Lupus

Other

Immunologic Other

Ear, Nose, Mouth, and Throat

Upper Respiratory Infection

Sinus

Other

Ear, Nose, Mouth, and Throat Other

Cancer

Medications

Please list current medications, over the counter medications (this includes eye drops, vitamins) you are presently taking.

Add new Medication

Social History

Do you use Tobacco Products?

No Yes

Type / Amount / How Long

Do you drink Alcohol?

No Yes

Type / Amount / How Long

Do you use Illegal Drugs?

No Yes

Type / Amount / How Long

Have you ever been exposed to, or infected with:

Gonorrhea

Syphilis

HIV

Hepatitis

None

Family History

Blindness: Relationship to You

Glaucoma: Relationship to You

Macular Degeneration: Relationship to You

Retinal Detachment: Relationship to You

Corneal Problems: Relationship to You

Cataracts: Relationship to You

Cancer: Relationship to You

Heart Disease: Relationship to You

Diabetes: Relationship to You

Lazy Eye: Relationship to You

I certify above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health .I authorize Bynum Eye Care to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eye care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to Bynum Eye Care insurance benefits otherwise payable to me. I understand that my eye care insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Authorizations

You are not obligated to sign any authorization below. You may revoke your authorization at any time. If you wish to do so, you must contact our office first.

Please list the family members or other persons, if any, whom we may inform about your general medical condition and your diagnosis

Add another name

I authorize Bynum Eye Care, PA office to schedule appointments with other physicians when needed. I understand that my name, date of birth, address, phone numbers, insurance information and diagnosis may be released when scheduling such appointments. I also understand no appointments will be made without my knowledge or consent.

Agree Disagree

I understand that if any prescriptions are prescribed to me, the prescription may need to be phoned, faxed, or mailed to the pharmacy. Therefore, my name, date of birth, and allergies will be released to the pharmacy of my choice to use.

Agree Disagree

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