Please Complete Reverse Side

Patient Information

Patient’s Sex: Age: Date Mo. Year Name: of Birth:

Address: Social Security #: Street Occupation: City State Zip Is today’s visit due to an accident? Y / N Phone Numbers: Home Work Cell Employer Name:

Work Address: Street City State Zip

Emergency Contact Information Emergency Contact Relationship Name: to Patient:

Phone Numbers: Home Work Cell

Financial Guarantor Information

(Who carries the insurance or is responsible for payment of the patient’s bill?)

Guarantor Relationship Name: to Patient: First MI Last Address: Date of Street Birth: Social Security #: City State Zip Phone Numbers: Home Work Cell Employer Name:

Work Address:

Please complete reverse side ↓ Glen Ellyn Ophthalmology Associates, Ltd.

Assignment of Benefits, Release of Information, Receipt of Privacy Policy and Consent to Treatment

Assignment of Benefits:

I request that payment of any authorized insurance and/or Medicare or Medicaid benefits be made on my behalf to Glen Ellyn Ophthalmology Associates, Ltd.

Release of Information:

I authorize the release of my medical information, including my diagnosis, records of any examination or treatment, and/or records of charges for services rendered to other doctors, hospitals or insurance companies concerned in my care and treatment. This release will be valid until I notify you otherwise in writing.

Consent to Treatment:

I voluntarily consent to such care and treatment as prescribed by the physician as is necessary in his or her medical judgment.

Privacy Policy:

I have received a copy of the privacy policy for Glen Ellyn Ophthalmology Associates, Ltd.

My signature below confirms that I have read the Assignment of Benefits, Release of Information, Receipt of Privacy Policy and Consent to Treatment and agree with its terms and conditions. It will remain in effect until revoked by me in writing. I consider an image of this document scanned into my medical record as valid as an original.

______Patient’s Signature (or Parent/Guardian) Date GLEN ELLYN OPHTHALMOLOGY ASSOCIATES, LTD. Robert J. Barnes, MD Kim A Lindenmuth, MD Sophia M. Sarkos, MD Varun K. Malhotra, MD 45 S. Park Boulevard, Suite 375, Glen Ellyn, Illinois 60137 (630) 858-4660 / Fax (630) 858-9511

Name: Age: Date:

PATIENT EYE HISTORY: 1. Is there a special problem that brings you in today? If yes, please explain:

2. Have you been told you have glaucoma? Yes _____ No _____

Age at diagnosis: _____ What was your highest eye pressure? ______

3. Have you been told you have a cataract, macular degeneration, diabetic eye disease, or other eye disease? Please list:

4. Do you wear glasses for distance? ____ For near? ____ Bifocals? ____

5. Do you currently have any problems in the following areas?

Yes No Explain Problem Loss of Vision Blurred Vision Distorted Vision (halos) Trouble Seeing Road Signs Glare / Light Sensitivity Dryness / Burning Itching / Mucous Discharge Excessive Tearing Infection of Eye Lid Double Vision

6. Please list all eye surgeries: Date:

7. Please list your eye medications: Medicine: Which Eye: How Often?

(please continue to the other side) GENERAL MEDICAL HISTORY: 1. Do you have any allergies to medications? Yes ___ No ___ (please list):

2. List current medications (other than eye medications):

3. List past operations (other than eye operations):

4. Do you currently have problems in any of the following areas?

Yes No (Please circle any that apply) General: Weight Loss Fatigue Loss of Appetite Heart Disease High Blood Pressure Cardiovascular: Irregular Heartbeat Heart Attack Angina Lungs: Asthma Emphysema Gastrointestinal: Stomach Ulcers Colitis Genitourinary: Kidney Disease Kidney Stones Skeletal: Arthritis: Rheumatoid Osteoarthritis Lupus Skin / ENT Skin Cancer Rosacea Hearing Loss Neurologic: Seizures Stroke Migraine Headaches Multiple Sclerosis Psychiatric: Depression Anxiety Endocrine: Thyroid Disease Diabetes Cancer: Other Problems: All Blank Responses are Negative: Yes _____ No _____ FAMILY EYE HISTORY: 1. Does anyone in your family have glaucoma? Yes _____ No _____

Relationship Age Diagnosed

2. Does anyone in your family have cataracts, Yes _____ No _____ macular degeneration, color blindness or other eye diseases?

Relationship Diagnosis

3. Which other major diseases are present in your family?

SOCIAL HISTORY: Occupation: Marital Status: Do you smoke? Yes _____ No ____ _ If Yes, how much? Who referred you to our office? Who is your family physician?

Physician Signature: Date: