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Toseef Hasan O.D. LTD
1050 N. Rohlwing Rd
Addison , IL 60101
PATIENT DEMOGRAPHICS/INSURANCE FORM
Patient's First Name:
M.I:
Last Name:
Date of Birth:
Sex:
Social Security #
- -
Race:
Ethnicity:
Preferred Language:
Address:
City:
State:
Zip:
Preferred Contact Method:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Confirm Email:
Employment Status:
Employer:
Occupation:
Student Status:
Marital Status:
Spouse Name:
Spouses Employer:
Where you referred by a Doctor?
Referring Doctor:
How were you referred to our clinic?
Emergency Contact: Name:
Relation to Patient:
Emergency Contact Home Phone:
Emergency Contact Work Phone:
Responsible Party:
Responsible Party Phone Number:
Responsible Party Address:
Responsible Party City:
State:
Zip:
INSURANCE
Primary Insured Name:
Primary Insured's Employer:
Primary Insured DOB:
Primary Insured's SSN:
- -
Patient Relationship to Primary Insured:
Medical Insurance:
Member ID/SS#:
Group Name or #:
Vision Insurance:
Member ID/SS#:
Group Name or #:
Secondary Insurance:
Member ID/SS#:
Group Name or #:
Secondary Subscriber Name:
Secondary Subscriber DOB:
Patient Relationship to Secondary Ins. Subscriber:
Self Pay:
Self Pay Patients must pay in full at the time of the service. Insurance will be verified and accepted, however, the co-pay, deductible and/or any non-covered charges must be paid in full at the time of the visit.
VISUAL AND MEDICAL HISTORY
Reason for today's visit?
Date of last eye exam?
By whom?
Do you presently wear?
If not currently wearing contacts, are you interested in trying them today?
If you wear contact lenses, do you know what type or brand?
Are your contacts comfortable?
How old are your glasses?
How old are your contacts?
Name of your Medical Doctor:
Dr's Phone:
Are you currently taking any medications?
(including oral contraceptives, aspirin, otc and/or herbal meds)
If so please list:
  Type Brand Name Generic Name Strength Dose Route Frequency Started On
Do you have allergies to any medications?
If so please list:
  Type Allergy-Medication Name Reaction Details Severity  
List all surgeries and/or hospitalizations you have had:
Are you pregnant or nursing?
Please List: Your Height in inches:
Your Weight in lbs:
OCULAR HISTORY
Check any of the following that you have had:
Are you interested in Laser Vision Correction?
Are you interested in hearing about treatments for dry eyes?
FAMILY MEDICAL HISTORY
Please Note any family history (Parents, Grandparents, Children, Siblings, Living or Deceased) for the following:
DISEASE/CONDITION
Yes / No / ?
RELATIONSHIP TO YOU
Blindness
Cataract
Glaucoma
Lazy/Crossed Eyes
Macular Degeneration
Retinal Detachment
Retinal Disease
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Lupus
Thyroid Disease
Other
IMMUNIZATION HISTORY
Please Note history for the following:
DISEASE
IMMUNIZATION DATE
Tetanus
Pertussis
Diptheria
Measles
Mumps
Rubella
Polio
Chicken Pox
Hepatitis A
Hepatitis B
Influenza
Disease Immunization Date
SOCIAL HISTORY
(This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.)
Smoking Status:
Do you use tobacco products?
If yes, type/amount/how long:
Do you use illegal drugs?
If yes, type/amount/how long:
Social History REVIEW OF SYSTEMS
Do you currently, or have you ever had any problems in the following areas:
Constitutional
Fever, Weight Loss/Gain
Integumentary (Skin)
Neurological
Headaches
Migraines
Seizures
Eyes
Loss of Vision
Blurred Vision
Distorted Vision/Halos
Loss of Side Vision
Dryness
Mucous Discharge
Sandy or Gritty Feeling
Foreign Body Sens.
Glare/Light Sensitive
Chronic Eye/Lid Infection
Styes or Chalazia
Flashes/Floaters
Tired Eyes
Itching
Excess Tearing/Watery
Psychiatric
Anxiety
ADD
ADHD
Allergic/Immunologic
Ears, Nose, Mouth, Throat
Allergies/Hay Fever
Sinus Congestion
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Throat/Mouth
Respiratory
Asthma
Chronic Bronchitis
Emphysema
Vascular/Cardiovascular
Diabetes
Heart Disease
High Blood Pressure
High Cholesterol
Vascular Disease
Gastrointestinal
Diarrhea
Constipation
Genitourinary
Bones/Joints/Muscles
Arthritis
Muscle Pain
Joint Pain
Lymphatic/Hematologic
Anemia
Endocrine
Thyroid/Other Glands
If you answered Yes to any of the above or have a condition not listed, please explain:
If you answered question (?) to any of the above, please explain:
I, the patient/guardian/responsible party, have accurately and truthfully completed the information listed on this form. I agree that all fees incurred are my responsibility regardless of insurance coverage. I acknowledge that I have received a “Notice of Privacy Practices” regarding the use and disclosure of my health information (Form is available at front desk or printable from our website).
By clicking “Yes” below you will have electronically signed this form
Your Name:
Date: