MedicalHistory-1214

MOUNTAINEER VISION CENTER, PLLC
DR. MARK D. ROBINSON | DR MICHAEL R. LOOPER
827 Fairmont Road, Suites 105-106 - Morgantown, WV 26501
Phone: (304) 296 – 3333; Fax: (304) 296 – 2220
http://www.mvcpllc.com

MEDICAL HISTORY
PATIENT’S NAME: _________________________________________________

DATE : _______________________

- PART ONE DO YOU HAVE ANY OF THE FOLLOWING MEDICAL CONDITIONS?
CONDITION

YES

NO

MEDICATIONS

HOW LONG

HYPERTENSION
HEART DISEASE
STROKE
DIABETES
THYROID DISEASE
ARTHRITIS
SINUSITIS
EMPHYSEMA
ASTHMA
KIDNEY DISEASE
HEADACHE
HEAD INJURY
LIVER DISEASE
SEIZURES/TREMORS
LUPUS
ROSACEA
HIGH CHOLESTEROL
CANCER

PART TWO DO YOU HAVE ANY OF THE FOLLOWING EYE CONDITIONS?
CONDITION

YES

NO

MEDICATIONS

HOW LONG

GLAUCOMA
MACULAR DEGENERATION
CATARACTS
RETINAL DETACHMENT
EYE INJURIES
EYE SURGERIES
BLINDESS
LAZY EYE

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Reviewed By: _________ Date: ________

DO YOU HAVE DRY EYES?

YES

DO YOU HAVE AIRBORNE ALLERGIES?

NO
YES

NO

LIST ALL ALLERGY MEDICATIONS BELOW:
________________________________________________________________________________________
ARE YOU ALLERGIC TO ANY MEDICINES?

YES

NO

IF YES, PLEASE LIST BELOW:
________________________________________________________________________________________

- PART THREE DO ANY OF YOUR FAMILY MEMBERS HAVE ANY OF THESE MEDICAL CONDITIONS?
CONDITION

YES

NO

WHICH FAMILY MEMBERS

HYPERTENSION
HEART DISEASE
STROKE
DIABETES
GLAUCOMA
CATARACT
RETINAL DETACHMENT
EYE SURGERIES
BLINDNESS
MACULAR DEGENERATION

- PART FOUR GENERAL QUESTIONS TO ASSIST US IN MEETING YOUR NEEDS AND CONCERNS.


PLEASE LIST THE REASON(S) FOR YOUR VISIT TODAY:
_________________________________________________________________________________________



DO YOU WANT (CHECK ONE)

GLASSES

CONTACT LENSES



ARE YOU PREGNANT?

YES

NO



DO YOU SMOKE?

YES

NO



DO YOU USE BIRTH
CONTROL?

YES

NO

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BOTH

Reviewed By: _________ Date: ________

- PART FIVE PATIENT INFORMATION – PLEASE FILL OUT FULLY & COMPLETELY. THANK YOU.
PATIENT’S INFORMATION
FIRST NAME: _____________________________ MI: _____ LAST NAME: ____________________________
ADDRESS: __________________________________________________________________
CITY: ________________________________________ STATE: ________

APT #: ________

ZIP CODE: _______________

HOME PHONE: _________________ WORK PHONE: ________________ CELL PHONE: _________________
E-MAIL ADDRESS: ___________________________________________________________________________
OCCUPATION: ______________________________ DATE OF BIRTH: __________________ AGE: _________
MARITAL STATUS:

SINGLE

MARRIED

LEGALLY SEPARTED

DIVORCED

EMPLOYER/SCHOOL: _____________________________________________ GENDER:

WIDOWED

MALE

FEMALE

SOCIAL SECURITY NUMBER: ____________________________________________________
FAMILY DR.: __________________________________ FAMILY DR. PHONE #: _______________________

GUARANTOR INFORMATION (IF NOT SELF OR PATIENT IS A MINOR)
FIRST NAME: ____________________ MI: ______ LAST NAME: __________________________
ADDRESS (IF DIFFERENT THEN PATIENT)____________________________________________
CITY: _______________________________STATE; _______________ZIP CODE: ____________
HOME PHONE: ________________ WORK PHONE: _____________CELL: __________________
EMPLOYER: _____________________________________________________________________

INSURANCE CARRIER INFORMATION
PRIMARY VISION INSURANCE: ________________________________

Page 3 of 6

ID #: _____________________

Reviewed By: _________ Date: ________

INSURED’S NAME: _____________________________________DATE OF BIRTH: __________________
ADDRESS IF DIFFERENT THEN PATIENT: ____________________________________________________
CITY: _________________________________STATE: _________ ZIP CODE: _______________________
RELATIONSHIP TO PATIENT: ___________________________________

MALE

OR

FEMALE

SECONDARY VISION INSURANCE: ______________________________

ID #:_____________________

INSURED’S NAME: __________________________________________DATE OF BIRTH _______________
RELATIONSHIP TO PATIENT: ___________________________________

MALE

OR

FEMALE

PRIMARY MEDICAL INSURANCE: ______________________________

ID #: _____________________

INSURED’S NAME: __________________________________________DATE OF BIRTH: ______________
ADDRESS (IF DIFFERENT THEN PATIENT)____________________________________________________
CITY: _________________________________STATE: _________ ZIP CODE: _______________________
RELATIONSHIP TO PATIENT: __________________________________

MALE

OR

FEMALE

SECONDARY MEDICAL INSURANCE: __________________________ID# __________________________
INSURED’S NAME: __________________________________________DATE OF BIRTH: ______________
RELATIONSHIP TO PATIENT: _________________________________

MALE

OR

FEMALE

REFERRAL INFORMATION

HOW DID YOU HEAR ABOUT US?
YELLOW PAGES
DAILY ATHENAEUM

NEWSPAPER AD

FRIEND/CO-WORKER / NAME: _____________________

MVC, PLLC WEBSITE WALKED IN TO CENTER

DO YOU HAVE A COUPON?

Page 4 of 6

(CIRCLE ONE)

YES

NO

OTHER: ________________

(IF YES, PLEASE PRESENT TO RECEPTIONIST.)

Reviewed By: _________ Date: ________

– PART SIX –

PATIENT FINANCIAL RESPONSIBILITY – PLEASE READ CAREFULLY
AND SIGN BELOW. THANK YOU.
I, HEREBY AUTHORIZE MOUNTAINEER VISION CENTER, PLLC TO APPLY FOR BENEFITS ON MY
BEHALF FOR COVERED SERVICES RENDERED BY THEM. I ALSO ASSIGN MY BENEFITS AND
REQUEST THAT ALL PAYMENTS FROM MY INSURANCE COMPANY BE MADE DIRECTLY TO
MOUNTAINEER VISION CENTER, PLLC. I AGREE TO PAY ALL CHARGES SHOWN BY
STATEMENTS, PROMPTLY UPON THEIR PRESENTATION, UNLESS CREDIT ARRANGEMENTS
ARE AGREED UPON IN WRITING.
I CERTIFY THAT THE INFORMATION I HAVE REPORTED WITH REGARD TO MY COVERAGE IS
CORRECT. I HEREBY AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY
IN ORDER TO PROCESS A CLAIM FOR PAYMENT IN MY BEHALF.
________________________________________________________________________________________
PATIENT/GUARDIAN SIGNATURE
DATE
________________________________________________________________________________________
PATIENT/GUARDIAN PRINTED
DATE

Page 5 of 6

Reviewed By: _________ Date: ________

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Reviewed By: _________ Date: ________