Branson Current Patient Update Form

BRANSON PATIENT INFORMATION UPDATE
Name 
First Name | Last Name
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First Name | Last Name
Mailing Address 
Street | City | St | Zip
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Street | City | St | Zip
Birthdate
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/
Please enter a valid date
Age
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Gender
Select...
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Social Security Number
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Mobile Phone
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Home Phone
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Email
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Employer (or school)
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Occupation (or grade)
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Marital Status
Select...
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Spouse or Parent's Name
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Race
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Communication Preference
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Preferred Language
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REVIEW OF SYSTEMS
Do you have problems with any of these systems?
Allergy
Cardiovascular (Hypertension, Heart)
Endocrine (Diabetes, Thyroid)
Gastrointestinal
Ear, Nose, Mouth, Throat
Blood/Lymphatic
Immunologic
Integumentary (Skin)
Musculoskeletal
Neurological
Psychiatric
Respiratory
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Please Explain
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MEDICAL HISTORY

Name of Family Physician
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Date of Last Exam
/
/
Please enter a valid date
Current Medications
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List any drug allergies
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Diabetes Type 1
Yes
No
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Diabetes Type 2
Yes
No
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Cancer 
Yes
No
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HIV Positive 
Yes
No
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Have you had any major operations?  
Yes
No
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Type of operation and year
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FAMILY HISTORY
Diabetes
Yes
No
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Relation
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Hypertension
Yes
No
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Relation
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Glaucoma 
Yes
No
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Relation
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Macular Degeneration 
Yes
No
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Relation
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Retinal Detachment 
Yes
No
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Relation
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Crossed/Lazy Eye 
Yes
No
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Relation
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Other Condition(s)
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Ocular History
Date of Last Eye Exam
/
/
By whom?
Have you had any eye surgeries?
Yes
No
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Type & Year
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Have you had any eye injuries?
Yes
No
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Type & Year
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Do you have any of the following?
Glaucoma
Cataracts
Double Vision
Blurry Vision
Dry Eyes
Macular Degeneration
Headaches
Itch/Burning
Glare at Night
Other
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Another Other Eye Condition(s)
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Do you wear contact lenses?
Yes
No
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What kind?
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Do you currently wear glasses?
Yes
No
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Whom may we thank for referring you?
LIFESTYLE QUESTIONS
What is the major purpose of your visit? 
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Are you having any vision problems?
Please explain
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Please explain
Do you have prescription sun wear? 
Yes
No
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Are you planning on new glasses today?  
Yes
No
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Do you want more information on Laser Vision Correction surgery?   
Yes
No
This question is required
Do you work at a computer?  
Yes
No
This question is required
Cigarettes/Tobacco  
Yes
No
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Alcohol  
Yes
No
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INSURANCE INFORMATION
Vision Insurance
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Subscriber Name
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Subscriber SSN
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Subscriber Birth Date
/
/
Please enter a valid date
Primary Medical Insurance
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Subscriber Name
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Subscriber SSN
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Subscriber Birth Date
/
/
Please enter a valid date
I hereby permit filing of claims to my insurance and or third-party carrier. Additionally, I assign to Ozarks Family Vision Centre (OFVC) any insurance or other third-party benefits available for service provided to me. I understand that OFVC has the right to refuse or accept assignment of such benefits. If these benefits are not assigned to OFVC, I agree to forward OFVC all payments I receive for services rendered to me immediately upon receipt. I also assume financial responsibility for services not covered or fully reimbursed by my insurance.


Electronic Signature 
Type your first and last name to sign.
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Type your first and last name to sign.
Date Signed 
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Submit