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