Enclosed Is Our New Patient Paperwork. Please Have This Andrea S
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Pejman Bakhtiary, M.D. Thank you for choosing Pacific Eye Institute! Pamela J. Bekendam, M.D. Peter D. Bekendam, M. D. Charisse M. Chin, D.O., M.P.H. Enclosed is our new patient paperwork. Please have this Andrea S. Ching, M.D. information completed prior to your appointment. Jesse A. Dovich, M.D. Daniel D. Esmaili, M.D. Mila J. Heersink, M.D. Please bring a list of your current medications and your Samuel C. Kim, M.D. Julie A. King, M.D. insurance card. Firas M. Rahhal, M.D. Richmond E. Roeske, M.D. W. Berwyn Smith, M.D. If you have a Power of Attorney, please bring a copy to be Aaron Savar, M.D. filed in your chart. Louis Savar, M.D. Nishant G. Soni, M.D. Daniel C. Su, M.D. Your new patient appointment will last approximately two Jeffrey J. Tan, M.D. Edward S. Yung, M.D. hours and you will be dilated. Please bring a driver. p a c i f i c e y e m d . c o m We look forward to seeing you on: BARSTOW 500 E. Mountain View St. Barstow, CA 92311 ___________________________________ p. 760.256.8791 f. 760.256.8710 EASTVALE at our______________________________ 12442 Limonite Ave., Suite 200 Eastvale CA 91752 p. 951.737.4000 f. 951.737.4040 location with Dr._____________________ HESPERIA 11959 Mariposa Rd. Hesperia, CA 92345 Feel free to phone our offices if you have any questions. p. 760.956.1100 f. 760.956.4705 RANCHO CUCAMONGA 8112 Milliken Ave., Suite 203 Rancho Cucamonga, CA 91730 p. 909.945.3563 p. 909.945.9400 (Laser Center) f. 909.945.9450 TEMECULA 41877 Enterprise Circle N., Suite 110 Temecula, CA 92590 p. 951.296.2244 f. 951.296.3602 UPLAND 555-591 North 13th Ave. Upland, CA 91786 555 Building p. 909.982.8846 | p. 800.345.8979 f. 909.949.3967 591 Building p. 909.982.8846 f. 909.949.3967 PATIENTPATIENT INFORMATION:INFORMAT Today’s Date__________________________ Acct #_________________________ Patient____________________________________________________________________________________________ Last First Middle Address___________________________________________________________________________________________ City and State___________________________________________________________________ Zip________________ Cell Phone (_____) ___________________ Home Phone (_____) ______________ Marital Status__________________ Date of Birth__________________ Age______ ☐ Male ☐ Female Social Security #_______________________ Driver’s License #__________________________________ E-mail Address____________________________________ Ethnicity: ☐ Hispanic/Latino ☐ Not Hispanic/Latino Race: ☐ American Indian/Alaska Native ☐ Asian ☐ African American/Black ☐ White ☐ Native Hawaiian/Other Pacific Islander Can we E-mail information to you periodically? ☐ YES ☐ NO Employer ______________Work Phone ____________ ININ CASE CASE OFOF EMERGENCY: Name _____________________________________Phone #___________________ _ PHARMACY:PHARMACY: Name_____________________________________ Phone #___________________ RESPONSIBLE PARTY if other than patient: Name_________________________________________________________ Social Security #_____________________ Address_______________________________________________________ Driver’s License #____________________ Employer______________________________________________________ Telephone__________________________ ACCIDENT:ACCIDENT: Industrial/Work Related? ☐ YES ☐ NO Auto Accident? ☐ YES ☐ NO Did you come through Emergency Room? ☐ YES ☐ NO Other Accident? ☐ YES _________________________ Date of injury____________________ Has employer been notified?________ Has carrier been notified?____________ HOW WERE YOU REFERRED TO THIS OFFICE? ☐ Internet ☐ Friend/Patient ☐ Other (specify)________________________________________________________ Physician/Optometrist: _____________________________________________________________________________ Name Address Primary Care Physician__________________________________________ Referring Medical Group______________ MEDICAL INSURANCE INFORMATION: (Attach copy of cards) MEDICAL INSURANCE INFORMATION (1) PRIMARY Insurance Co.: _______________________________________ Group/Policy#__________________ Policy Holder_______________________________________________________ Member/ID #__________________ Policy Holder Date of Birth_____________________________________________ Policy Holder ☐ Male ☐ Female Patient Relationship to Policy Holder__________________________________________________________________ (2) SECONDARY Insurance Co.: Insurance Company__________________________________________________ Group/Policy #__________________ Policy Holder_______________________________________________________ Member/ID #___________________ Policy Holder Date of Birth_____________________________________________ Policy Holder ☐ Male ☐ Female Patient Relationship to Policy Holder___________________________________________________________________ OFFICE USE ONLY PN: ________________ Medical History Questionnaire DOS: _______________ Name: ________________________________________________ Date of Birth: ________________________ Vision Correction - Do you wear glasses? ☐ No ☐ Yes Do you wear contact lenses? ☐ No ☐ Yes Reason(s) for visit – In your own words, please describe the reason for your visit today: _______________________________________________________________________________________________ _______________________________________________________________________________________________ Visual Function Questions – Please check if you are experiencing difficulty with any of the following: No Yes No Yes Reading Small Print Watching Television Reading Traffic or Street Signs Driving at Night Driving in Bright Light Seeing Steps, Curbs or Stairs Glare or Halo Floaters or Flashes Dry, Red, Sandy or Itchy Feeling Other: Allergies – Please list all known medication (including intravenous contrast dye and anesthetics) and environmental (including seasonal, food and latex) allergies or indicate ☐ NO KNOWN ALLERGIES. Allergy Reaction Allergy Reaction Current Medications – Please list all current prescribed medications (including eye drops and medical cannabis), over-the-counter medications, vitamins and supplements or indicate ☐ NO MEDICATIONS. Name Dosage Frequency Name Dosage Frequency Review of Symptoms – Please check if you are experiencing any of the following: N Y Constitutional N Y Cardiovascular N Y Endocrine N Y Integumentary Fatigue Chest Pain/Pressure Cold Intolerance Hives Fever Irregular Heartbeat Heat Intolerance Rash N Y HEENT N Y Gastrointestinal N Y Neurological N Y Musculoskeletal Bulging Eyes Abdominal Pain Imbalance Back Pain Hearing Loss Constipation/Diarrhea Headache Joint Stiffness Sinus Problems Nausea/Vomiting Memory Difficulty Muscle Weakness N Y Respiratory N Y Genitourinary N Y Psychiatric N Y Hematologic Asthma Pain with Urination Depressed Mood Bleeding Cough Blood in Urine Irritability Bruising Wheezing Tender Lymph Nodes Current Height: _________________________________ Current Weight: ________________________________ Past Ocular and Surgical History – Please check if you have received treatment (including eye drops and medical cannabis) or had surgery for any of the following conditions (note type): No Yes No Yes Cataract: Cornea: Glaucoma: LASIK: Oculoplastic: Retina: Other: Other: Personal and Family Health History – Please check if you or a family member have / have had any of the following or indicate ☐ NO RELEVANT PERSONAL HISTORY ☐ NO RELEVANT FAMILY HISTORY. Self Mother Father Sister Brother Allergies Anxiety Auto-Immune Disorder (note type) Blindness Cancer (note type) Cataracts Corneal Disease Diabetes (note type) Depression Glaucoma Heart Disease High Blood Pressure High Cholesterol Lazy Eye Macular Degeneration Migraines Retinal Disease Seizure Disorder Stroke Thyroid Disorder Other: Other: Females: Are you currently pregnant? ☐ No ☐ Yes Are you currently breastfeeding? ☐ No ☐ Yes Social History Have you ever used tobacco? ☐ No ☐ Yes - If yes: ☐ Former ☐ Current Every Day ☐ Current Some Day Tobacco Product: ☐ Cigarette ☐ Cigar/Cigarillo ☐ Pipe ☐ Snuff/chew ☐ Smokeless ☐ Other: _______________ Do you drink alcohol? ☐ No ☐ Yes - If yes: _____ drinks per ☐ Day ☐ Week ☐ Month ☐ Year Do you drink or consume caffeine? ☐ No ☐ Yes - If yes: ☐ Coffee ☐ Energy Drinks ☐ Soda ☐ Tablets Occupation: _____________________________________ Status: ☐ Full Time ☐ Part Time ☐ Retired/Other INFORMED CONSENT FOR DILATED EYE EXAMINATION In the course of your care, whether today or in the future, it is important for your doctor to evaluate your retina, macula and optic nerve with a dilated examination. Dilating eye drops are used to enlarge the pupil of the eye to allow the physician to obtain a better view of the inside of your eyes. Dilation frequently changes (blurs) vision for a length of time which varies from person to person and may make bright lights bothersome. It is not possible to predict to what degree your vision will be affected. Driving may be difficult immediately after the examination. If you are concerned about these problems, you may wish to make alternative transportation arrangements. The majority of patients do drive after dilation with the assistances of temporary sunglasses, which we will provide after your examination. Adverse reactions, such as a rises in eye pressures causing pain may be triggered by the dilating drops. It may be necessary to lower the pressure by the use of eye drops, oral medication and/or laser treatment. There is also a possibility of an allergic reaction to the dilating drops. The decision to undergo dilation is yours. You may choose not to have the dilation