Medical History Questionnaire Today's DateName: Home Phone:-------------------------- -------------------Address: Cell Phone:~-------------------City: State:__ Zip: Employer _Date of Birth: Guardian or Parent (if patient is a minor): --------------------------Last Eye Exam: Last Medical Exam: _

Medical HistoryDo you have any allergies to medications? 0 Yes 0 NoIf yes, please explain: _

List any medications you take (including oral contraceptives, aspirin, over the counter medications and homeremedies:--------------~--------~--~--~--~-----------------------------------List all major injuries, surgeries and hospitalizations: _

Select any of the following diagnoses that you have had:o Crossed Eyes 0 Lazy Eye 0 Glaucoma 0 Retinal Disease 0 Cataracts 0 Eye Infections/Injury If so,when? --------------------------------Are you pregnant or nursing? 0 Yes 0 NoDo you wear glasses? 0 Yes 0 No If yes, how old is your present pair lenses? _DDyou wear contact lenses? 0 Yes 0 No If yes, how old is your present pair oflenses? _Type of contact lenses: 0 Rigid 0 Soft 0 Extended Wear 0 OtherAre they comfortable? 0 Yes 0 No

F ". H" tamnv IS orvDisease/Condition Yes No Siblina Father Mother GrandparentBlindnessCataractCrossed EyesGlaucomaMacularDegenerationRetinalDetachmentArthritisDiabetesHigh BloodPressureKidney DiseaseLupusThyroid DiseaseOther:

Social History (This information is kept strictly confidential. However, you may discuss this portion directly with thedoctor if you prefer.) 0 Yes, I would prefer to discuss my Social History information directly with the doctor. .Do you drive? 0 Yes 0 No If yes, do you have visual difficulty when driving? 0 Yes 0 No If yes, pleasedescribe: ---------------------------------------------------------------Do you use tobacco products? 0 Yes 0 NoDo you drink alcohol? 0 Yes 0 NoDo you use illegal drugs? 0 Yes 0 No

If yes, type/amountlhow long: _If yes, type/amount/how long: ----'_If yes, type/amount/how long: _

Review of Body Systems: Do you currently have any problems in the following areas?

Body System Yes No Yes NoCONSTITUTIONAL EAR, NOSE, MOUTH, THROATFever, Weight Loss/Gain 0 0 AllergieslHay Fever 0 0

Sinus Congestion 0 0INTEGUMENTARY (Skin) 0 0 Chronic Cough 0 0NEUROLOGICAL - Dry ThroatlMouth 0 0Headaches 0 0Migraines 0 0Seizures 0 0

RESPIRATORYAsthma 0 0

EYES Chronic Cough 0 0Loss of Vision 0 0 Dry ThroatIMouth 0 0Blurred Vision 0 0Loss of Side Vision 0 0 VAS~CARDIOVASCULARDouble Vision 0 0 Diabetes 0 0Dryness 0 0 High Blood Pressure 0 0Mucous Discharge 0 0 Vascular Disease 0 0Redness 0 0Sand or Gritty Feeling 0 0' GASTROINTESTINALItchin 0 0 Diarrhea 0 0gBurning 0 0 Constipation 0 0Foreign Body Sensation 0 0 Other 0 0Excess TearingIWatering 0 0Glare/Light Sensitivity 0 0 GENITOURINARYEye Pain or Soreness 0 0 GenitalslKidneylBladder . 0 0Chronic Infection of Eye or Lid 0 0 Other 0 0Sties or Chalazion 0 0Flashes in Vision 0 0 BONES/JOINTSIMUSCLESFloaters in Vision 0 0 Rheumatoid Arthritis 0 0Tired Eyes 0 0 Joint Pain 0 0

Other 0 0ENDOCRINEThyroid/Other Glands 0 0 LYMPHATICIHEMATOLOGIC

Anemia 0 0ALLERGIC/IMMUNILOGIC 0 0 Bleeding Problems 0 0

Other 0 0PSYCHIATRIC 0 0

SIGNATURE:

For your convenience, we would like to offer our Annual Eye Exam Notification Program. Haveyour annual eye exam reminder sent directly to your personal computer and/or phone by:

Email 0 Email Address:Text Message 0 Cell Number:Both 0

Please check one or both methods of notification above and sign below.

Signature: ...,...- Date: _

r--------------------------------.--------.----- ...-.----.---.

Patient Name: --------------------------------------------------------NOTICE OF PRIVACY PRACTICES

I have received a copy of the Notice Of Privacy Practice

Patient Signature Date _

RESPONSffiILITY FOR PAYMENT

I agree that in consideration of services to be rendered, I assume financial responsibility and agree to pay DrAlan Schwartz OD PC all charges for such services incurred, including all non-covered services. Even thoughinsurance may be filed, I agree to be fully responsible for paying any co-pay, co-share, or deductable at time ofservice. We will do our best to determine your responsibility, but the fmal determination of patientresponsibility will be made by the insurance company once the claim is filed. Any additional charges not paidfor at the time of your visit will be billed and are payable upon receipt.

Patient Signature Date

IF YOUHA VE VISION OR MEDICAL INSURANCE PLEASEPRESENT YOUR CARD BEFORE YOUR EXAM OR YOU MAY BERESPONSIBLE FOR FULL PAYMENT.

INSURANCE SIGNATURE ON FILE

I certify that the information given by me in applying for insurance andlor Medicare payment is true andcorrect. I authorize my doctor to act as my agent in helping me obtain payment of my insurance andlorMedicare benefits, and I authorize payment of these benefits directly to Dr. Alan Schwartz O.D., P.C. on mybehalf for any services and materials furnished. -

I authorize any holder of medical information about me to release to the Centers for Medicare and MedicaidServices and its agents any information needed to determine these benefits payable to related services. If I haveother health insurance coverage (as indicated in Item 9 of the CMS-1500 claim form or electronically submittedclaim), my signature authorizes release of the above medical information to the insurer or agency shown, andauthorizes my doctor to act as my agent, as above.

Patient Signature Date