Annual Patient History Update If you have been a patient at Bethel Vision Center in the pas, then please fill in the data on this form. If we do not find you in our records we will ask you to fill out a NEW PATIENT form before a doctor can see you. You may enter dates by clicking on the calendar icon next to the data field or you may enter a date directly into the textbox. If you enter the date into the text box it must be in the form MM/DD/YYYY. If you see a date of 02/18/1867 it means you have not entered a date in that field. SSN if you enter it must be in the from 999-99-9999. First Name and Last Name are required. WHen you are done filling in the data, press the Save button. If you have made any errors a pop up message will list them. You can then correct the named item. Once your data is correct and you press the Save button, a popup message will indicate success. If you wish to print a copy of your data, please do so after saving it first. Once you save the data it cannot be edited. If you wish to edit after saving, then press the Home button and then click the New Patient button again. If you do this within 20 minutes of the time saved it, you will be able to see your previously entered data and change it. You can then save it again. This will send multiple copies of your information to the doctor. Patient Information First Name Last Name DOB Address City State Zip Email Home Phone Cell Phone Work Phone SS# Occupation Employer Insurance Section Please provide information for both your Medical health insurance and your Vision insurance. Vision Insurance is mainly a wellness benefit and is provided to help reduce your costs for preventive eye care while the Medical insurance exists for more serious eye problems. Medical Insurance Section Primary Insurance Name Primary Insurance ID# Vision Insurance Section Vision Insurance Name Vision Insurance ID# Primary Care Physician Address & Phone Number Patient Medical History General Information Please let us know the date of your last physical exam and update us about your medications, allergies to medications, major illnesses, injuries or surgeries. List all medications and doses (mg) you are taking, including vitamins, calcium, aspirin, herbs and supplements. List all allergies to medications: Have you had any hospitializations, surgery or procedures since you last filled out the information? Have any close relatives (parents, siblings, or children) been recently diagnosed with any medical or vision problems? Health Habits Do you drink alcohol? If checked, describe how much and how often. Do you smoke? If checked, describe how much and how often. Previous Tobacco User? Do you exercise daily? Do you exercise 3-4 times per week? Do you rarely exercise? Last Physical Exam Date Have you had Eye Pain in the past year? Have you had Itchy Eyes in the past year? Have you had Dry/Gritty eyes in the past year? Have you had Blurred Vision in the past year? Have you had Redness in eyes or lids in the past year? Review of Systems Do you currently have any problems in the following areas? If yes, please check the appropriate box. Constitutional Changes (Fever/ weight changes) Skin Changes (Rashes, Growths) Neurological CHanges (Headaches, Seizures) Ear, Nose and Throat (Sinus congestion, Soreness) Respiratory (Asthma, Chronic Bronchitis) (Cardiovascular (Heart Disease, High Cholesterol, High blood pressure) Gastrointestinal (Chronic diarrhea, Ulcers) Genitourinary (Kidney, Bladder) Musculoskeletal (Arthritis, Back pain, joint pain) Hematologic / Lymphatic (Anemia, Bleeding problems) Endocrine (Diabetes, Thyroid, Hormone imbalances) Psychiatric (Depression, Anxiety) Allergy / Immune (Hay fever, Immune Deficiencies) You may click the PRINT button to print a local copy of this data. If you already saved it you do not have to save it again unless you wish to update what you entered. Home
