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Name Relationship Name Relationship
Insured’s Date of Birth
Male Female
Name of Primary Insurance Company Insured’s First Name MI Insured’s Last Name
Name of Primary Insurance Company Insured’s First Name MI Insured’s Last Name
M F
Social Security Number Date of Birth Primary Phone Number Cell Phone Number
Emergency Contact Emergency Contact Phone Number
E-mail Address Guardian Person Responsible for Account
Street Address City State Zip
First Name MI Last Name Preferred Name
Welcome To Aloha Vision Consultants Carlton Yuen, M.D. and Jason Tokunaga, M.D.
Thank you for choosing us for your eyecare needs. We are delighted to have you as a patient and appreciate the confidence you placed in us. Please take a moment to complete the following information. If you have any questions, please do not hesitate to ask.
PRIMARY INSURANCE INFORMATION
Patient Status: Single Married Other Full Time Student Part Time Student Employed
Patient Relationship to Insured: Self Spouse Child Other
SECONDARY INSURANCE INFORMATION
M F Patient Relationship to Insured: Self Spouse Child Other Insured’s Date of Birth
CONSENT TO RELEASE: Authorization is hereby given to Drs. Yuen & Tokunaga to disclose and be furnished by any and all health care infor-mation including medical records, reports, x-rays, diagnostic test results, bills, and payment records with respect to medical treatment or qualified healthcare operations provided to: a) Any health insurance plan/company that provides coverage for me for the purpose of payment of charges. b) Any insurance company that provides liability insurance coverage for Drs. Yuen & Tokunaga for the purpose of evaluating treatment
rendered to me. c) To leave messages regarding my appointments of health information on my answering machine/voicemail. I give permission to speak to the following regarding my medical information and treatment:
This authorization shall cover the period of time from my first visit to my last. I understand that I can revoke this authorization at any time. This authorization shall end 2 years from the date of my last visit. I release Drs. Carlton Yuen & Jason Tokunaga from all legal responsibility that may arise from this authorization. PLEASE READ: We ask that the patient’s portion is paid at the time services are rendered unless other arrangements are made in advance. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance. Accounts 90 days old are subject to collection fees. There will be a service charge on all returned checks. Payment from my insurance is to be paid directly to Aloha Vision Consultants. I understand that my insurance will be billed as my primary insurance. You may be required to fill out a questionnaire for billing multiple insurance companies. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made when the claim is processed.
Mr. Miss Mrs. Ms.
A notice of Aloha Vision Consultant Notice of Privacy Practices has been made available to me. I understand my rights regarding my medical records.
Signature Date
Referring Physician Address City State Zip Phone
Primary Care Physician Address City State Zip Phone
Name
PATIENT HISTORY AND INFORMATION
PRIMARY CARE PHYSICIAN
Primary Care Physician and Clinic Name
REFERRING PHYSICIAN
Referring Physician and Clinic Name
HEALTH HISTORY
What is the main reason for today’s exam?
When was your last vision exam? When was your last health exam?
Past Illnesses or Injuries: Past Surgeries: Current Medications: Current Eye Drops: Medicines that cause reactions or sensitivities: Specific Allergies:
EYE HISTORY
Yes No
Yes No
Yes No
Cataract
Glaucoma
Blindness
Yes No
Yes No
Yes No
Retinal Detachment
Macular Degeneration
Color Blindness
Yes No
Yes No
Yes No
Amblyopia (Lazy Eye)
Strabismus (Eye Turn)
Other
GENERAL HEALTH CONDITION
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Fever
IƛƎƘ /ƘƻƭŜǎǘŜNJƻƭ
Cancer
Ears, Nose, Throat
Cardiovascular
High blood pressure
Respiratory (Asthma)
Gastrointestinal
Kidney
Muscle, Bones, Joints
Skin
Neurological (MS)
Anxiety or Depression
Thyroid
Diabetes
Blood, Lymph
Allergic
Pregnant?
FAMILY HISTORY
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Amblyopia (Lazy Eye)
Blindness
Cataract(s)
Color Blindness
Glaucoma
Macular Degeneration
Retinal Detachment
Strabismus (Eye Turn)
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Lupus
Stroke
Thyroid Disease
Others
Name
MEDICAL HISTORY QUESTIONNAIRE
SOCIAL HISTORY
Current Occupation: Years: Employer:
Do you drink alcohol? No If yes, how much/often? Occasional 1 Per Day 2-3/day 4+/day
Do you smoke? No If yes, how much/often? Occasional 1/2 pack/day 1 pack/day 1+ pack/day
Method of Tobacco Intake: Smoking Chewing
Do you use nutritional supplements (vitamins, etc.)? Yes No
Do you use illegal drugs? Yes No
Do you drive? Yes No
Do you have glare problems? Yes No
Do you have visual difficulty when driving? Yes No
Do you have problems with night vision? Yes No
SPECTACLE LENS HISTORY
Do you currently wear glasses? Yes No Since
Type of glasses Full Time Part Time Distance Close (Reading)
Glasses owned Single vision Bifocals Trifocals Backup Safety Sports Progressive
Have you had trouble in the past with glasses? Yes No
Do you wear sunglasses? Yes No
Are your sunglasses your current prescription? Yes No
CONTACT LENS HISTORY
Do you currently wear contact lenses? Yes No Since
Type and brand of contact lenses?
www.AlohaVisionConsultants.com Drs. Carlton Yuen & Jason Tokunaga
1029 Kapahulu Avenue #502 Honolulu, HI 96816
Tel: (808) 782-1861 Fax: (808) 218-7830
99-128 Aiea Heights Drive #304 Aiea, HI 96701 Tel: (808) 688-6898
Consent to Obtain Patient Medication History
Patient medication history is a list of prescription medicines that our practice providers, or other providers, have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history. The collected information is stored in the practice electronic medical record system (EHR/EMR) and becomes part of your personal medical record. Medication history is very important in helping healthcare providers treat your symptoms and/or illness properly and in avoiding potentially dangerous drug interactions. It is very important that you and your provider discuss all your medications in order to insure that your recorded medication history is 100% accurate. Some pharmacies do not make drug history information available, and your drug history might not include drugs purchased without using your health insurance. Also over-the-counter drugs, supplements, or herbal remedies that patients take on their own may not be included.
I give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers. This includes prescription medicines to treat AIDS/HIV and medicines used to treat mental health issues such as depression.
________________________________________ _______________________________________ Patient Name (Print) Name and Relationship of Legal Representative ________________________________________ _______________________________________ Patient Signature (or Legal Representative) Date
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