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The Focal Pointe
2724 Capital Circle NE Suite 1
Tallahassee, FL 30308
850-385-4444
Richard.Hamilton@thefocalpointe.com

 

 

 

 

Personal Information:

Dr. Mr. Mrs. Ms. Miss Rev
First Name:
Last Name:
Street:
City:
State:
Zip:
E-Mail:
Home Phone:
Work Phone:
Birthdate:
Social Security #:
Marital Status:
Preferred Language:
Race:
Hispanic or Latino Yes No

Other family members who are patients at The Focal Pointe

Responsible Party:    Relationship:
Comments:
(e.g., address, if different from patient's)

Insurance Information:

Primary Insurer:
Aetna  BCBS  CHP  United  Medicare 
None  Other 

(Note: Some health plans have vision coverage included in their benefits.)

Primary Insurance ID#: (example: XJU123-45-7889)

Secondary Insurer:

(e.g., Medicare Supplements)

Secondary Insurance ID#:

Reason For Visit:


Review Of Systems:

Constitutional                                                    Gastrointestinal
Cancer                                                         Acid Reflux
Developmental                                            Celiac Disease
Fatigue Syndrome                                       Chrohn's
Other                                                            Ulcer

Ear / Nose / Throat                                          Genitourinary
Dry Mouth                                                   Kidney Disease
Hearing Loss                                               Pregnant
Laryngitis                                                     Prostate Disease
Sinusitis                                                        STD, Herpes, Chlamydia
Other                                                            Other

Neurological                                                    Muskuloskeletal
Cerebral Palsy                                              Ankylosing Spondylitis
Epilepsy                                                         Arthritis
Migraines                                                      Fibromyalgia
Multiple Sclerosis                                         Gout
Stroke /CVA / TIA                                        Osteoarthritis
Other                                                              Osteoporosis
                                                                             Other
Psychiatric                                                       Integumentary
Attention Deficit                                            Eczema
Anxiety                                                           Herpes Simplex / Cold Sores
Bipolar                                                            Herpes Zoster / Shingles
Depression                                                     Psoriasis
Other                                                              Rosacea
                                                                             Other
Respiratory                                                     Endocrine
Asthma                                                            Hormonal Dysfunction
Bronchitis                                                         Thyroid Dysfunction
Chronic Obstruction                                         Type 1 Diabetes
Emphysema                                                      Type 2 Diabetes
Sleep Apnea                                                     Other
Other
Hematologic / Lymphatic                                  Allergic / Immune
Anemia                                                             Drug Allergies
High Cholesterol                                             Environmental Allergies
Blood Loss                                                       Lupus
Ulcer                                                                Rheumatoid Arthritis
Other                                                                Sjogren's Syndrome
                                                                              Other


     





Medications:
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Medication Allergies
Other Allergies
                                                          
 
   
 
 

Past Ocular History:

Patching                       Injury
Retinal Detachment      Retinal Degeneration       
Amblyopia                   Macular Degeneration
Other                           Keratoconus
Cataract                       Glaucoma
Inflammatory Disorder  Negative
Glaucoma Suspect        Retinal Hole
Surgery                        Strabismus

Family History:

Medical                             Ocular
Thyroid                       None
Hypertension               Other
None                          Retinal Detachment
Other                          Glaucoma
Diabetes                     Cataract
Cancer                       Macular Degeneration
                                       
Other

Social History:

Drinking Yes No
Tobacco Use Yes No

Smoking Status:
Never Smoker
Former smoker
Current some day smoker
Current every day smoker


Additional Comments / Concerns:


 

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