MEDICAL QUESTIONNAIRE & ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

www.visionplace.com

By filling this out prior to your visit, Dr. Desai and Dr. Naik will able to review your chart and expedite your visit.
We also recommend to upload your copy of insurance cards and ID.
(all * - contact information, date of birth, medication, and last 3 check boxes need a response)

Contact Information (required)

First Name

Middle Initial

Last Name

Address

City

State

Zip

Email (required)

Enter Phone Number (required)

Personal Information

Date of Birth

Gender

Male Female

Social Security

Emergency Contact

Occupation

Last Eye Exam

For Existing Patients...

Any changes since your last visit?

yes no

What has changed?

new insurance

new vision symptoms

new medications

Medical and Vision Insurance Information

Health Insurance Carrier

Primary Policy Holder's Name

(self, spouse, parent, partner, other)

Policy Holder DOB

Policy Holder SSN

Policy Id Number

Policy Group Number

Policy Phone Number

Vision Plan Name

Vision Plan Id Number

Upload your driver's license and Insurance ID Card (medication list if available) Please upload your copy of your insurance cards and ID. Medication list can be uploaded too.

Add file

Please upload a file

Reason for Visit and Primary Care Physician

Other reason:

Family Primary Doctor

Primary Doctor Contact Info

Ocular (Vision) History

If you have had eye surgery before, please list

History of Present Illness

List any other symptoms:

Patient History

Indicate any history for the following conditions:

Blindness

Cataracts

Glaucoma

Macular Degeneration

Retinal Detachment/Disease

If yes to Diabetes, please answer the following:

Diabetes Type

Type 1 Type 2

Enter your HbA1C

Last Blood Sugar Recording

Diabetes Doctor's Name and Contact info:

Last Date of Diabetic Exam

If yes to Cancer,

Please state what kind of cancer:

List any other health conditions:

Do you smoke?

Yes No

If yes, for how long and how many packs?

Do you consume alcohol?

Yes No

If yes, how often?

Family Ocular and Systemic History

AIDS/HIV

Mother

Father

Sister

Brother

Grandparent

Aunt/Uncle

Arthritis

Mother

Father

Sister

Brother

Grandparent

Aunt/Uncle

Blindness

Mother

Father

Sister

Brother

Grandparent

Aunt/Uncle

Cancer

Mother

Father

Sister

Brother

Grandparent

Aunt/Uncle

Cataract

Mother

Father

Sister

Brother

Grandparent

Aunt/Uncle

Diabetes

Mother

Father

Sister

Brother

Grandparent

Aunt/Uncle

Glaucoma

Mother

Father

Sister

Brother

Grandparent

Aunt/Uncle

Heart Disease

Mother

Father

Sister

Brother

Grandparent

Aunt/Uncle

High Blood Pressure

Mother

Father

Sister

Brother

Grandparent

Aunt/Uncle

High Cholesterol

Mother

Father

Sister

Brother

Grandparent

Aunt/Uncle

Kidney Disease

Mother

Father

Sister

Brother

Grandparent

Aunt/Uncle

Macular Degenration

Mother

Father

Sister

Brother

Grandparent

Aunt/Uncle

Retinal Detachment/Disease

Mother

Father

Sister

Brother

Grandparent

Aunt/Uncle

Thyroid Disease

Mother

Father

Sister

Brother

Grandparent

Aunt/Uncle

Medications

Are you taking any medications? (required)

Yes No

List all current medications, including vitamins, supplements:

Are you allergic to any medications?

Yes No

if yes, please list:

Symptoms

Do you have any symptoms of shortness of breath, fever, cough or have been COVID-19 positive in the last 14 days?

Yes No

Please share anything else you would like us to know. ie favorite hobbies, activities, food, or any additional requirements.

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

Purpose of this form is to obtain acknowledgement of receipt of our Notice of Privacy Practices and to document our good faith effort to obtain that acknowledgement

The law requires that Vision Source makes every effort to inform you of your rights related to your personal health information. By my checking the boxes below, I acknowledge:

Click each box

the Vision Source’s Notice of Privacy Practice and agree to continue my care with Vision Source

This is how your health information may be used and disclosed and how you can access your information. We will NOT disclose your records unless you direct us to do so or unless the law authorizes or compels us to do so.

my Financial Responsibility

Accept full financial responsibility should my insurance deny a pay for any service rendered

I acknowledge that I have been provided this practice's Privacy Policy and agree to allow the practice to use medical and insurance information I have provided to pre-authorize services.

By checking this box and typing my intials below, I am electronically signing this acknowledgement.

Your initials

Date

Your information will be encrypted.