Today's Date:    Mail to: Eye Care Specialists, P.S.  500 Port Drive  Clarkston, WA 99403
BirthDate    Male  Female      SS#
Patient Name        
  (First Name)                         (MI)      (Last Name)
Address   Home Phone# 
City/State/Zip
E-Mail Address               Cell# 
Employer's Name  Phone   ext 
Address  Job Title
Marital Status Single Married Widowed Separated Divorced
Spouse's Name    BirthDate
Address (if diff)  SS#
Employer's Name  Phone   ext 
Address  Job Title
Person to Call In Case of an Emergency:
Name  Relationship to patient 
Address  Home Phone# 
City/State/Zip  Work Phone# 
Financial Information        Who is responsible for account:
Self Spouse Parent** Guardian/Power of Attorney**
**Please fill in Parent/Guardian Information
Parent/Guardian Name    BirthDate
Address (if diff)  SS#
Employer's Name  Home Phone# 
Address  Work Phone# 
Insurance Information:
Primary Insurance  ID#  Group# 
Subscriber Name  DOB 
Coverage for:     Self   Family    Both
Effective Date  If Medicare:  Part A Only Part B OnlyBoth A&B
Secondary Ins  ID#  Group# 
Subscriber Name  DOB 
Coverage for:     Self   Family    Both
Effective Date  If Medicare:  Part A Only Part B OnlyBoth A&B

*** I, hereby assign the benefits of any applicable insurance coverage to Eye Care Specialists to be applied toward the payment of the services rendered for which I acknowledge financial responsibility. I understand that I am financially responsible for all charges whether or not paid by insurance.  I hereby authorize the provider to release all information necessary to secure the payment of benefits.  I authorize the use of this signature on all insurance submissions.  I authorize the doctors of Eye Care Specialists, and their staff to provide medical, nursing, emergency care, or such treatment as necessary
Responsiblilty Party Signature X ______________________________________________  Date______________

HEALTH / FAMILY / SOCIAL HISTORY

Patient Name Primary Care Physician

On the following please check which eye is affected and rank accordingly
1=rarely  2=occassionally  3=daily

EYES:  R      L   Rank EYES:  R      L   Rank EYES:  R      L   Rank EYES:  R      L   Rank
Blurry Distortion Sandy/Foreign Body Sty  
Swelling Loss of Vision Double Vision Pain  
Red Droopy Eyelid Excess Tearing Headaches            
Glare Dry/Burning Eyes Turn In/Out Migraines            
Floaters Eyes Crossed Itch
Mucus Flashes Halos
Glasses No Yes How Long Contacts No Yes Hard Soft
Past Eye Trauma: Past Eye Surgeries:

HEALTH:  Please check all that apply. If checked, please explain:

Heart Diabetes Myasthenia Gravis
Stroke Hepatitis Alzheimer
High Blood
     Pressure		 STD Senility
High
     Cholesterol		 HIV/AIDS Mental Handicap
Cancer Anemia Estrogen Replacement
Lupus Transfusion Pregnant/Planning
Kidney
     Disease		 MS Breast Feeding
Thyroid Fibromyalgia Lungs/Breathing
Parkinson Arthritis Sinus
     Congestion/Infection
Aneurysm Gout Dry Throat
Other    
List Current Medications:

List Allergies to Medications:

List Past Surgeries:


FAMILY HISTORY:  Please check the following if a family member is affected. Specify which family member.

Glaucoma Blindness Retinal Detachment
Arthritis Diabetes Macular
     Degeneration
Lupus Kidney Heart Attack
Stroke TB Thyroid
Sjogrens Cancer High Blood
     Pressure

SOCIAL HISTORY:          Your Occupation:  

Smoking  No  Yes  Occasional  Weekly  Daily    Quit/How long ago?   
Alcohol  No  Yes  Occasional  Weekly  Daily 
Exercise  No  Yes  Occasional  Weekly  Daily 
Driving  No  Yes    Weight Change   Gain  Loss        Explain