J - Buena Vista Eye Medical Center

&H
BUENA VISTA EYE MEDICAL CENTER
Nombre
Fecha de ultima histxxia medica.
Fecha de Nadmiento.
Liste tDdos los medicamentos que esta tomando (recetadosysinreeetar):
Tienealergfaaalgunmedfcamento? SI
NO
SilarespuestaesSl, nombre los medfeameientos
_
Apunte totes las enfermedades graves y/b testones desde su ultima vlslla
J
Liste totes lasoperaciones que hatertido.
c^ionkMrinpmhtemas en las sigufentes areas? Si esasiporfavorexpfigue
SI
runs (vision pobre. dolor, uorosos. irritacion, etc)
GENERAL (fiebre, catentura, perdida de peso,
incrementoenelj
OITO.I'lARIZ.GARGAmAidrflcurladparaoir,
congestion en tenarferdolorden^lK~<aecttrg SB
CARDIOVASCULAR (presion anaTefcj
GASTROINTESTINAL (
estrenimiento- hernia ufcera, eto.j
GENITAI^sisNON^VEJK^CA^aJonnar, orina
fhscuerrterneri^&ttoW^oiosarnaTfflo&^l
milieres - esta usted embarazada? O tectando?
MUSCULOS, HUESOS, CO"-0*1711!^.J^"****
artriBs. dotoren lasartJcufanJones. imrlamacion
piel foerruoas. irritacion, qranos, ronchas)
NEUROLOGIA (Dolores de cabesa, errtumetinfento,
paralysis, convulciones)
PSYCHIATRICO fcnsiedad, depresion, insomia)
ENDOCRiNO (debetes.hrpcrtrrokfemo, etc)
SANGRE/ FUNCION UYMFATICA (sangrado,
anemia, choleslsfoLproblemas retecionados con
transfuoiondesansre )
ALERGIAS/liWWNOUK^ieaDrnudos, 'mflamacton
ITwarinnmr>chas.comeson,lupusLetoj
Cancer, ThyroWes, Artrate
|otra errferrn^fa^ congenita
NO
Expfique
HISTORIA SOCIAL
,
^_ _,.——r|Su
vision Iimita alguna actividad de su vida
diaria (conducir, teer, hacer deportee,
trabajar etc)
Le han realizado alguna vez una transfusion de sangre?
Toma usted alcohol?
SI/ NO
JFuma? Si/NO Si Fuma, Cuanto
F1RMA DEL DOCTOR.
YES/ NO
Sibebe, cuanto _
Por cuanto tiempo ha fumado__
Fecha.
'
•
PATIENT CONSENT FORM
Iunderstand that, under the Health Insurance Portability &Accountability Act of1996 (HIPAA), I
have certain rights to privacy regarding my protected health information. I understand that this
information can and will be used to:
• Conduct, plan and direct my treatment and follow-up among the multiple healthcare
providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such asquality assessments and physician
certifications.
Ihave been informed by you ofyour Notice ofPrivacy Practices containing a more complete
description of the uses and disclosures of my health information. Ihave been given the right to
review such Notice ofPrivacy Practices prior to signing thisconsent Iunderstand that this
organization has the right to change its/^^
contact this organization atany time atthe address betow to obtain a current copy ofthe Notice of
Privacy Practices.
Iunderstand that Imay request in writing that you restrict how my private information is used or
disclosed to carry out treatment, payment or heaJm care operations. Ialso urnier-stand yw
required to agree to my requested restrictions, but if you do agree then you are bound to abide by
such restrictions.
Iunderstand that Imay revoke this consent in writing at any time, except to the extent that you have
taken action relying on this consent
Patient Name:
Signature:
Relationship to Patient
Date:
nawwiMiumfac