&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