NEW / UPDATED PATIENT INFORMATION(Please Print)

Patient Name __________________________________ Date ________________________

Patient Address ___________________________City ___________State _____Zip _________

Home Phone (______) _______________ Business Phone (_______) ___________________

Social Security Number ________________________ Email____________________________

Sex _____M _____ F Age _______ Birthdate _______________ Marital Status ___________

Spouses Name _____________________________ Spouses Employer ___________________

Emergency Contact Person ___________________ Phone Number (_____) ________________

Nearest Relative ____________________________Phone Number (_____) ________________(Not Living With You)

Patient Employed By ________________________ Business Address_____________________

Family Physician ___________________________ Practice Location ________________ (City)

Hospital Affiliation of Your Family Physician _______________________________________

Referring Doctor_______________________________________________________________

How Did You Learn of Our Practice? ______________________________________________

Purpose of Visit ________________________________________________________________

Who Is Responsible For This Account? _____________________________________________

AUTHORIZATION OF PAYMENT BENEFITS TO PHYSICIANI authorize any holder of medical or other information about me to release to my insurancecarriers or intermediaries, any medical information needed for this or any other related medicalclaim. I request payment of authorized insurance benefits to be made to Dr. Jeffrey S. Rohr forany services rendered to me. I understand payment for office visits is appreciated at the timeservice is rendered. I understand that I am responsible for the costs of all services rendered tome by Jeffrey S. Rohr, D.O., p.c. d/b/a Rohr Eye & Laser Center (the "office"). I agree to paythe costs of all services rendered to me by the office, including any costs that are not covered bymy insurance. I understand and agree that payment of my account is due within fourteen (14)days from the date of invoice and that if not paid within fourteen (14) days, a $5.00 late fee, oranother amount permitted by law, will be added to my account and may continue to be added tomy account until paid in full. I agree to pay all costs and expenses incurred, including reasonableattorney fees, incurred by the office in the collection of my account in the event I fail to pay it infull within fourteen (14) days from the date of invoice. I hereby authorize photocopies of thisform to be as valid as the original.

Patient or Responsible Party Signature ____________________________ Date ____________

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PATIENT HISTORY RECORD

Patient Name__________________________________________Date____________________

Please answer the following questions about your medical status and history:

1. Have you ever been treated for any medical conditions? (Please provide the year diagnosed)

DiabetesDiet controlled Year_________ Type________________ Type _________________Oral medication Year_________ ____________________ _____________________Insulin Year_________ Year ________________ Year__________________

Cancer Type________________Year _______________ Year _______________ How often_____________

Year _______________ Year _______________ Year________________

Hepatitis Type_______________Year _______________ Year _______________ Year ________________

Year _______________ Year _______________ Year ________________

Year _______________ Year _______________ Year ________________Other________________________________________________________________________

2. Have you ever had any eye diseases?

pia (Lazy Eye)

Laser Treatment, if yes please Explain____________________________________________________________________________________________________________________________

3. Have you eveIf Yes, please list type and year of surgery:_________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Have you ever been hospital________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Patient Medication/Allergies

Patient Name:___________________________________________Date:_________________________

1. _________________________________ 4. _________________________2. _________________________________ 5. ________________________3. _________________________________ 6. ________________________

Please List ALL Medications Including Prescriptions, Eye Drops, Over The Counter,Aspirin, Herbal, Vitamins, Minerals, Dietary Nutritional Supplements and Injections

(such as Insulin).MEDICATION DOSAGE

(ie. mg,ml)HOW OFTEN

(ie. daily, twice a day)HOW TAKEN

(ie. Oral, injection)

OFFICEUSEONLY

Review of Symptoms

Do you have any of the following problems?: Yes NoFever, unexplained weight loss/gain, fatigue, night sweats, chillsEar/Nose/Throat problems (hearing loss, sinus problems, sore throat, etc.)Heart problems (chest pain, irregular beat, fainting spells, attack, etc.)Lung problems (shortness of breath, TB, wheezing, coughing, etc.)Gastrointestinal problems (heartburn, stomach pain, diarrhea, vomiting, etc.)Urinary problems (pain, discomfort, blood in urine, loss of control, etc.)Skin problems (rashes, excessive dryness, etc.)Musculoskeletal problems (muscle pains, joint pains, swollen joints, etc.)Neurologic problems (numbness, weakness, headaches, paralysis, seizures, etc.)Psychiatric problems (depression, anxiety, nerves, bipolar disorder, etc.)

If Yes to any of the above, circle symptom and please explain:____________________________________

______________________________________________________________________________________

Family and Social History

Do any medical or eye diseases run in your family? (e.g. diabetes, heart disease, stroke, glaucoma, lazyeye, cancer, macular degeneration, retinal detachment, blindness, retinal degeneration, etc.)

Yes No If Yes, please circle disease andexplain:__________________________________

______________________________________________________________________________________

Do you smoke? Yes No If Yes, how much?___________Packs per day.

Do you drink alcohol? Yes No If Yes, how much?___________________________

If employed, how many hours per week do you work?__________________________________________

Comments:____________________________________________________________________________

______________________________________________________________________________________

Patient Signature:_______________________________ Date:______________________

Doctor Signature:_______________________________