2551 Compass Rd, Suite 125
Glenview, IL 60026
2845 Sheridan Rd, Suite 903
Chicago, IL 60657

New Patient Form

New Patient Form

Please list ALL active treating physicians (i.e. pulmonologist, oncologist, internist, cardiologist, etc.)

Collection of the following information is encouraged by federal health agencies. This information is used to monitor
and improve the quality of care provided to all patients.

Leave empty if decline response*

Patient Financial Obligation Agreement

I understand that all applicable copayments and deductibles are due at the time of service. I understand that any outstanding statements past 90 days are subject to collection status and may incur additional charges I agree to be financially responsible and make full payment for all charges not covered by my insurance company. I authorize my insurance benefits be paid directly to Adam J Cohen, MD for services rendered. I authorize representatives of Adam J Cohen, MD to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim.

Notice of Privacy Practices: Acknowledgement of Receipt

I acknowledge that I was provided with a copy of the Adam J Cohen, md Notice of Privacy Practices (NOPP).

Information Disclosure and Consent
Adam J Cohen, MD will provide you with the health plans that your provider accepts. If you decide to be treated by our provider and he does not accept your health plan, you will be asked to sign a consent form agreeing that you accept treatment from that provider.



I read and agree to all of the above (Financial Agreement, Notice of Privacy, Insurance Information)
*Please refer to our website: www.theartofeyes.com for a list of insurances accepted by your provider.

Have you EVER had any of the following:

Asthma/Breathing Problems

YesNo

Arthritis

YesNo

Bleeding/Clotting Disorder

YesNo

Blood Pressure Disorder

YesNo

Blood Transfusion

YesNo

Bowel/Stomach Problems

YesNo

Cancer

YesNo

Cholesterol Disorder

YesNo

Diabetes

YesNo

Eye Disorder (i.e. Glaucoma/Cataract)

YesNo

Women Only: Gynecological Issues

YesNo

Heart Disease/Disorder

YesNo

Lung Disorder

YesNo

Liver Disease

YesNo

Neurological Disorder/Chronic Headaches

YesNo

Psychiatric Disorder/Illness

YesNo

Pulmonary Embolism/DVT

YesNo

Stroke

YesNo

Seizure or Epilepsy

YesNo

Thyroid Disorder

YesNo

Urinary/Kidney Disorder

YesNo

Please list any other medical illnesses or problems and provide details for any of the above conditions:

Please list all past surgeries and hospitalizations and the approximate date:

Procedure/Hospitalization






Date






Complications






Please list all past surgeries and hospitalizations and the approximate date:

Relative

Condition and Description

Living

If deceased, at what age?

Mother

YesNo

Father

YesNo

Sibling

YesNo

Other

YesNo

Do you currently smoke? YesNo

Consume alcohol YesNo

If yes, how many drinks/week?

Women Only: Any past pregnancies YesNo

Do you have any allergies to medications or other substances (pets, food, etc.)? YesNo

Allergy

Reaction

Allergy

Reaction

Please list ALL of your current medications, including over the counter medications, supplements and herbs:

Medication

Dose

Medication

Dose

Review of Systems
Please indicate ALL that you have experiences in the last 6 – 12 months

Constitutional

Fever

YesNo

Chills

YesNo

Sweats

YesNo

Fatigue

YesNo

Feeling Poorly

YesNo

Weight Gain

YesNo

Weight Loss

YesNo

Unexp. weight change

YesNo

Sleep Disturbances

YesNo

Other

YesNo

Head, Eyes, Ears, Nose, and Throat

Vision problem

YesNo

Decreased Hearing

YesNo

Double Vision

YesNo

Light Sensitivity

YesNo

Itchy Eyes

YesNo

Red Eyes

YesNo

Eye Pain

YesNo

Runny Nose

YesNo

Neck Stiffness

YesNo

Nosebleed

YesNo

Congestion

YesNo

Snoring

YesNo

Dry Mouth

YesNo

Flu-Like Symptoms

YesNo

Sore Throat

YesNo

Hoarseness

YesNo

Ringing in Ears

YesNo

Vertigo

YesNo

Earache

YesNo

Other

YesNo

Cardiovascular

Chest Pain

YesNo

Cold Extremities

YesNo

Irregular Heart Rhythm

YesNo

Palpitations

YesNo

Cold Hand or Fee

YesNo

Other

YesNo

Leg Swelling

YesNo

Leg Pain w/walking

YesNo

Respiratory

Shortness of breath

YesNo

Cough

YesNo

Chest Congestion

YesNo

Wheezing

YesNo

Coughing up Sputum

YesNo

Other

YesNo

Coughing up blood

YesNo

Rapid Breathing

YesNo

Gastrointestinal

Abdominal Pain

YesNo

Painful Swallowing

YesNo

Vomiting Blood

YesNo

Bowel Incontinence

YesNo

Rectal Pain

YesNo

Diarrhea

YesNo

Blood in Stool

YesNo

Vomiting

YesNo

Nausea

YesNo

Other

YesNo

Changes in Bowels

YesNo

Black/Tarry Stools

YesNo

Decreased Appetite

YesNo

Yellow Skin

YesNo

Neurological

Headache

YesNo

Tremor

YesNo

Tingling

YesNo

Confusion

YesNo

Coordination

YesNo

Other

YesNo

Unsteady

YesNo

Dizziness

YesNo

Memory Lapse/Loss

YesNo

Seizures

YesNo

Burning Sensation

YesNo

Numbness

YesNo

Disorientation

YesNo

Decreased Strength

YesNo

Poor

YesNo

Fainting (syncope)

YesNo

Musculoskeletal

Joint Pain

YesNo

Neck Pain

YesNo

Back Pain

YesNo

Other

YesNo

Limb Pain

YesNo

Joint Swelling

YesNo

Muscle Cramps

YesNo

Muscle Pain

YesNo

Muscle Weakness

YesNo

Leg Swelling

YesNo

Genitourinary

Frequent Urination

YesNo

Heavy Period Bleeding

YesNo

Discharge

YesNo

Bleeding

YesNo

Irregular Monthly Cycles

YesNo

Pelvic Pain

YesNo

Incontinence

YesNo

Urinary Urgency

YesNo

Painful Urination

YesNo

Other

YesNo

Painful Intercourse

YesNo

Nocturia

YesNo

Itching

YesNo

Change in Libido

YesNo

Integumentary

Rash

YesNo

Skin Cancer

YesNo

Itching

YesNo

Skin Wound

YesNo

Dry Skin

YesNo

Other

YesNo

Unusual Growth

YesNo

Change in a Mole

YesNo

Psychiatric

Depression

YesNo

Anxiety

YesNo

Other

YesNo

Hematologic/Lymphatic

Easy Bruising

YesNo

Other

YesNo

Easy Bleeding

YesNo

Swollen Lymph Nodes

YesNo

Endocrine

Excessive Thirst

YesNo

Cold Intolerance

YesNo

Heat Intolerance

YesNo

Changes in Hair

YesNo

Changes in Skin

YesNo

Other

YesNo

Additional Ophthalmology Information

Chief Complaint: What is the main primary problem with your eye(s), eyelids or face, and when if you first notice
symptoms or were you told or your diagnosis?

Past History:

Do you have or have you had any of the following problems or conditions?
Please answer ALL questions – indicate YES or NO. If the answer is YES, please provide a brief explanation.

Glaucoma

YesNo


Cataract

YesNo


Droopy Eyelids

YesNo


Double Vision

YesNo


Dry Eye

YesNo


Tearing

YesNo


Lady Eye (Amblyopia)

YesNo


Crossed Eyes (strabismus)

YesNo


Macular Degeneration

YesNo


Retinal Detachment

YesNo


Eye Injury

YesNo


Eye Inflammation

YesNo


Thyroid Eye Disease/Graves’ Disease

YesNo


Laser Surgery

YesNo


Other

YesNo


Previous Eye Surgery? YesNo


Previous face, brow, eyelid, tear duct, or orbital surgery?
YesNo


Previous cosmetic facial procedures (Botox, fillers, peels, laser, etc.)YesNo


Sensitive to soaps?

YesNo

Tapes?

YesNo


Do you ever take Aspirin, Plavix, Coumadin, Lovenox? YesNo


History of slow or poor wound healing

YesNo


History of keloids

YesNo


History of cold sores, herpes, shingles

YesNo


History of skin cancer

YesNo


History of other cancer

YesNo

Hepatitis

YesNo


Positive HIV Test

YesNo

Problems tolerating anesthesia:

Local:

YesNo

General:

YesNo

Family History:

Glaucoma

YesNo

Macular Degeneration

YesNo

Thyroid Disease

YesNo


In addition to our medical services, we also specialize in aesthetic/cosmetic and rejuvenation procedures of the face
and eyes. To ensure we are meeting our patient’s needs, we ask that you complete the following questionnaire.

Please check all that apply.

These are the areas of interest or concern to me:

Droopy upper or lower eyelids


Excess skin on the eyelids


Droopy or angry appearing eyebrows


Bag under the eyes


Bumps or skin tags on the eyelids or face


Wrinkles and fine lines


Skin discoloration or hyperpigmentation


Dark Circles or puffiness around the eyes


Desire for longer, fuller or darker eyelashes


Botox


Dermal fillers


None of the above concerns me

Do we have your permission to send information via email/main or call you regarding the above
procedures and updates about our practice?

YesNo, please do not contact me


How did you hear about us (please specify)

My physician


A friend or family member


Internet


Other