Patient Questionnaire
Name: ______, ______Date: _____/_____/______
(Last) (First)
Ocular Surface Issues
Report the FREQUENCY of the following symptoms you are experiencing by checking Never,
Sometimes, Often or Constant using the numbering system below:
0 = Never, 1 = Sometimes, 2 = Often, 3 = Constant
SYMPTOMS / 0 / 1 / 2 / 3Dry, Gritty, or Scratchy
Soreness or Irritation
Burning or Watering
Eye Fatigue
Report the SEVERITY of your symptoms using the ratings list below:
0 = No problems
1 = Tolerable – not perfect but not uncomfortable
2 = Uncomfortable – irritating but does not interfere with my day
3 = Bothersome – irritating and interferes with my day
4 = Intolerable – unable to perform my daily tasks
SYMPTOMS / 0 / 1 / 2 / 3 / 4Dry, Gritty, or Scratchy
Soreness or Irritation
Burning or Watering
Eye Fatigue
Are You Interested in Any of the Following Services?
Laser Vision Correction(LASIK, PRK, Laser-
Assisted Cataract
Surgery, Implantable
Lenses)
Circle YES NO
/ Cosmetic Facial Treatments
(Facial Lines & Wrinkles
Lines around Nose/ Mouth)
Circle YES NO / Cosmetic EyeLid Treatments
(Botox ®, Juvéderm® / Fillers,
Eyelid Surgery)
Circle YES NO
For office use only: Doctor: Aminari Bodman
Butler Codner
Crosby Katzman
Morris Viechnicki
Total Speed Score (Frequency + Severity) =______
OSC Reviewed with Doctor Y N Cosmetic Facial Reviewed by Doctor Y N
LVC Reviewed by Doctor Y N Cosmetic Eyelid Reviewed by Doctor Y N
COMMERCIAL INSURANCE
I authorize Morris Eye Group, dba: Eyecare Solutions Inc., a medical corporation, to submit a claim to my medical/vision insurance carrier or its intermediaries for all covered services or products provided by the practice. I understand that I am responsible for any Deductible, Co-Insurance, Co-Payment and any Non-Covered Services. I understand that it is the policy of Eyecare Solutions, Inc. to collect for these items at time of service. I understand that it is my responsibility to update my insurance file whenever I change insurance carriers. I understand that failing to provide current carrier information makes me immediately responsible for balances that other wise would have been paid by my medical/vision carrier. I understand that if I join an HMO I will inform the providers of Eyecare Solutions, Inc. prior to scheduling any care such that the staff can identify my eligibility for care with this practice.
Medical Insurance Company:______
Policy/Group Number: ______
Vision Insurance Company: ______
Policy/Group Number: ______
Date: ______
Signature: ______
This assignment of benefits shall remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered valid as an original.
PRIVACY PRACTICES ACKNOWLEDGEMENT
I hereby acknowledge that I received, read and understand the Notice of Privacy Practices that are implemented by Morris Eye Group, Eyecare Solutions, Inc AMG. I understand that the physicians and employees of the practice will make reasonable efforts to protect my privacy and keep my patient information confidential and secure.
Patient Print Name: ______Date: ______
Signature of Patient: ______Date: ______
MEDICARE
Name
Medicare Number
I request that payment of authorized Medicare benefits be made on my behalf to Jeffrey Morris, MD Comprehensive Eyecare, dba: Eyecare Solutions, Inc, a medical corporation, for any service furnished to me by a provider of the group. I authorize any holder of medical information about me to release to the health care financing administration and its agents any information needed to determine these benefits for the benefits payable for related services. In Medicare assigned cases, the provider agrees to accept the charge determination of Medicare carrier and I am responsible for the Medicare Deductible, Co-Insurance or the 20% Medicare does not pay, and any Non-covered services.
My signature below further verifies that I have not joined an HMO or other entity in which my Medicare benefits have been relinquished. I understand that I am responsible for any charge incurred if I have not met my deductible or if I have signed my Medicare benefits over to an organization such as an HMO with which Jeffrey Morris, M.D. Comprehensive EyeCare, dba: EyeCare Solutions, Inc. does not have a contract.
Signature
MEDIGAP
I request that payment of authorized Medigap benefits be made either to me or on my behalf to Jeffrey Morris, M.D. Comprehensive EyeCare, dba: EyeCare Solutions, Inc., for any services provided to me by a provider of the group. I authorize any holder of medical information about me to release to my Medigap insurer any information needed to determine these benefits for payable for related services.
This assignment shall remain in effect until revoiked by me in writing. A photocopy of this assignment is to be considered valid as an original.
Signature
Permission to Disclose Information
I, ______(print name), date of birth ______
Give permission for the doctors and staff of Morris Eye Group to disclose my medical and billing
information to:
Spouse/Significant other: ______
(print name)
Child/Children: ______
______
(print name)
Friend/Family: ______
______
(print name)
Caregiver/Other: ______
______
(print name)
Signed: ______Date: ______
PRACTICE POLICIES CONCERNING CONTACT LENSES
New Patients and New Contact Lens Wearers:
To be fit for contact lenses we require that our patients complete all three components of the eye examination: medical exam, refraction, and contact lens measurements. In some instances, due to patient preference and time constraints, a separate second appointment with our contact lens specialist may be necessary. Even if one is an experienced contact lens wearer all three components of the examination must be completed. To reiterate, there are three separate professional examination fees: medical, refraction, and contact lens. In some instances, patients may have medical and/or vision insurance that may be applicable to these fees. Patients are provided with their contact lenses during their initial fitting. Professional fees are payable when the products are ordered. The fees for different contact lens products vary and our opticians can review these costs and answer any other questions regarding contact lenses.
We recommend that all of our contact lens patients have a pair of glasses on hand. You may purchase glasses from our practice or any other vendor you choose. After your refraction you will be given a copy of your glasses prescription. This prescription is good for two years. Additionally, wearing sunglasses is an important product to one’s eyes from UV rays. Sometimes contact lenses make one more sensitive to bright light. If you only wear contact lenses occasionally, then you will need a pair of prescription sunglasses.
Contact lenses are medical devices that are placed on the eye. It is important that we determine that they are properly fit, that they are not compromising corneal health, and that there are no other problems related to the wearing time or infection. Once ordered, our opticians will spend time educating you on insertion, removal, proper care and your own specific wearing regimen. Once dispensed, we will be seeing you for a series of follow-up appointments over the next 90 days to confirm that you are correctly fit.
After 90 days, you may order replacement lenses from us or any other vendor of your choice. We will be happy to provide you with a contact lens prescription once we are confident you are correctly fit. Contact lens prescriptions are good for one year.
Established Patients and Long-Time Contact Lens Wears:
If you currently wear contact lenses we recommend an annual medical eye examination to ensure the health of the eye and the fit of the lenses. Moreover, from year to year there is often a change in vision and there may need to be a correction made in your contact lens or glasses prescriptions. If there is a significant change in your refraction, a second contact lens examination may be required by our contact lens specialist. Fees for these services may be applied to any form of insurance that provides you benefits for this care. The process for fitting and dispensing an updated pair of contact lenses is identical to the initial process described previously.
Once this process is complete, we would once again be pleased to have you reorder your lenses through our dispensary or provide you with your contact lens prescription to be used with any other vendor.
BASIC DO’S AND DON’TS
DO use only solutions recommended by your doctor.
DO check for lens damage before each wear.
DO replace your contact lens case once a month to avoid infection.
DO keep all of your follow-up appointments and annual eye exams.
DO wear sunglasses with proper UV protection.
DO have a spare pair of glasses on hand.
DO carry your prescriptions when traveling.
DO call us if you have questions or problems.
DO call to reorder before you run out of disposable lenses.
DON’T wet your lenses with your saliva.
DON’T rub your eyes when wearing your lenses.
DON’T insert a lens from a packet that is damaged.
DON’T forget to clean and disinfect non-disposable lenses.
Please sign below that you have read and understand our practice policies regarding contact lenses. Thank you.
______
Signature of Patient (or responsible party) Date
______
Print Patient Name Date
MEDICAL HISTORY QUESTIONNAIRE
Name______Today’s Date______
Date of Birth______Date of last eye exam______
List any medications, eye drops, and the dosage you currently take (prescription and/or over the counter).
Medication Dosage
______
______
______
______
______
______
______
______
______
Do you have allergies to any medications? Yes No If yes, list the medications:
______
______
List any surgeries (cataract, lasik, heart, appendectomy, etc) and their dates:
______
____________
Health Conditions:
GENERAL ______Yes No Explanation of Problem ______
Fever ______
Weight Loss/Gain ______
Other ______
EAR, NOSE, THROAT
(sinus, ear infection, chronic cough, dry mouth,… ______
CARDIOVASCULAR (heart, vessels, etc.) ______
RESPIRATORY (asthma, emphysema, etc.) ______
GASTROINTESTINAL
(stomach, ulcers, intestinal disease, etc.) ______
GENITAL, KIDNEY, BLADDER ______
MUSCLES, BONES, JOINTS (arthritis, etc.) ______
SKIN (acne, psoriasis, skin cancer, etc.) ______
NEUROLOGICAL (multiple sclerosis, etc.) ______
PSYCHIATRIC (anxiety, depression, insomnia) ______
ENDOCRINE (diabetes, hypothyroid, etc.) ______
BLOOD/LYMPH (cholesterolemia, anemia,HBP.) ______
ALLERGIC/IMMUNOLOGIC
(hayfever, lupus, sjogrens, etc.) ______
Continued On Other Side…
FAMILY HISTORY ______
Relationship (check all applicable)
DISEASE Yes No Mother Father Sibling Grandparent______
Glaucoma ______
Macular Degeneration ______
Cancer ______
Diabetes ______
Heart Disease ______
HighBloodPressure______
Lupus ______
Stroke ______
Thyroid Disease ______
Cataracts ______
Other ______
SOCIAL HISTORY ______
Have you ever tried to wear contact lenses?
Yes No If YES, how long did you wear them? ______
Do you currently wear glasses?
Yes No If YES, how long have you had the current prescription? ______
Do you drink alcohol? Yes No If YES.. Occasional 1 per day 2-3 per day 4+ per day
Do you smoke? Yes No If yes, ... Occasional ½ pack/day 1 pack per day 1+ pack/day
If yes, how many years have you smoked? ______
Have you ever smoked in the past? Yes No If yes, how many years did you smoke? ______
Caffeine? Yes No How many cups a day? ______Drug use? Yes No
______
Preferred Pharmacy:______
Name:______
Address/Location:______
Phone Number:______
Patient Portal:
A Way to Communicate Faster with Morris Eye Group
Morris Eye Group has an exciting new way for you to communicate with our office.
You can now schedule appointments, view your medical history and renew your medications, all online by using our Patient Portal. Patient Portal is a secure online resource that gives you convenient 24-hour access to personal health information from anywhere with an internet connection, using a secure username and password. You can sign up today. Just ask a Morris Eye Group staff member when you check out.
How To Sign Up:
When scheduling your appointment you will receive a numeric code called a Token. This Token will be emailed to you by our staff.
Once you receive your token, Log onto www.nextmd.com and follow these steps:
The first screen will show you two tiles side by side. “Already a member” on the left, and “I am new here” on the right.
· If you have already registered: enter your username and password, then click “LOG IN”
· If you have not previously registered: click “I AM NEW HERE” and follow these directions.
1. Read the Terms and Conditions and click “I ACCEPT” at the bottom of the page.
2. This will bring you to a new page titled “New to Patient Portal?” Please select the option for “I was given an enrollment token.”
3. You will then be directed to enter your enrollment token, birth date, and email address. Once you have entered the information, select “NEXT”
4. This will bring you to a new page called “Create enrollment credentials”
Register your information including a username, password, a “login security authorization” question and answer, as well as your “password recovery credentials” question and answer. Then click “SUBMIT”
5. You are now logged in to the patient portal. An email will be sent to you confirming your enrollment.
Once logged in, several square tiles will appear on the home page of your dashboard including:
Inbox, Upcoming Appointments, Reminders, Results, and Medications
· If you do not have any upcoming appointments, reminders, etc.- nothing will show in those tiles
Navigating the Patient Portal:
On the top of your homepage there are 8 buttons with drop down options including:
Home, Mail, Schedule, My Chart, Payments, Renew Medications, Patient Education, Settings
The Home button will take you back to your homepage at any time.
The Mail button allows you to compose and view email correspondence to our staff and your doctor.
· Incoming messages will appear in your INBOX. You can access your Inbox from the homepage or under the drop-down option for “Inbox”
· To send a message, click the option for “Compose Message.”
The Schedule button allows you to request appointments and view any upcoming appointments.
· When scheduling an appointment, click on the drop down tab named “Request Appointment”