Welcome!

YOUR POINT OF VIEW, THERAPEUTIC OPTOMETRISTS

NAME: ______________________________ AGE: ___ Today’s Date: ____________ New Patient:_______________

BIRTH DATE: ____/____/_____ M / F MARITAL STATUS M / D / S OCCUPATION:____________________________________ ADDRESS:________________________________________ HOBBIES/SPECIAL VISUAL NEEDS:____________________ CITY/ST./ZIP:______________________________________ DATE OF LAST EYE EXAM __________________________ TELEPHONE #:____________________________________ SS# OR Ins ID: ____________________________________

MAIN REASON FOR THIS EXAM ____________________________________________________________________________________

OCULAR HISTORY: Please check the appropriate boxes pertaining to yourself or your family.

Yes No Family Yes No Family Yes No Family

Glaucoma ❏❏❏ Surgery ❏❏❏ Inflamatory disorders ❏❏❏ Cataracts ❏❏❏ Double vision ❏❏❏ Macular degeneration ❏❏❏ Blurred vision ❏❏❏ Floaters ❏❏❏ Other _______________________________ Name of any eye drops used _______________________________________________ If you have ever had eye surgery, please describe and give approximate dates ____________________________________________________

CONTACT LENSES Do you wear or have you ever worn contacts? ❏ Yes ❏ No Typical replacement schedule _________________________ Type of contacts ❏ Soft ❏ Hard/Gas Permeable ❏Disposable ❏Toric Do you know what brand? ____________________________ Do you ever sleep in your lenses? ❏ Yes ❏ No What cleaning solution do you use? ____________________

GENERAL HEALTH HISTORY: Please try to give complete and accurate information, since any of these conditions can affect the health or treatment of the eyes directly, indirectly, or can be a sign of a more serious health condition. This information is completely confidential.

Allergic/Immunologic Musculoskeletal Cardiovascular

Yes No Family Yes No Family Yes No Family Drug allergies ❏❏❏ Fibromyalgia ❏❏❏ Heart disease ❏❏❏ Environmental allergies ❏❏❏ Muscular Dystrophy ❏❏❏ Hypertension ❏❏❏ Rheumatoid arthritis ❏❏❏ Osteoarthritis ❏❏❏ Stroke ❏❏❏ Lupus ❏❏❏ Ankylosing spondylitis ❏❏❏ Vascular disease ❏❏❏ other _______________________________ other ________________________ other __________________________

Gastrointestinal Neurological Constitutional Crohn’s ❏❏❏ Multiple sclerosis ❏❏❏ Developmental disablity ❏❏❏ Colitis ❏❏❏ Epilepsy ❏❏❏ Weight loss ❏❏❏ Ulcer ❏❏❏ Alzheimers ❏❏❏ Fever ❏❏❏ Digestive ❏❏❏ Parkinsons ❏❏❏ Fatigue ❏❏❏ other _______________________________ Cerebrovascular ❏❏❏ Trauma ❏❏❏

other ________________________ other __________________________ Genitourinary STD, viral herpetic, chlamydia ❏❏❏ Psychiatric Endocrine other _______________________________ Depression ❏❏❏ Non-insulin diabetes ❏❏❏

Panic disorder ❏❏❏ Insulin diabetes ❏❏❏ Ears, Nose, Mouth & Throat Schizophrenia ❏❏❏ Thyroid dysfunction ❏❏❏ Upper Resp. Tract inf. ❏❏❏ other ________________________ Hormonal dysfunction ❏❏❏ Ear ache ❏❏❏ other __________________________ Runny nose ❏❏❏ Hematologic/Lymphatic Sore Throat ❏❏❏ Anemia ❏❏❏ Respiratory Ringing-tinitis ❏❏❏ Large volume blood loss ❏❏❏ Cigarette smoker ❏❏❏ other _______________________________ Leukemia ❏❏❏ Asthma ❏❏❏

other ________________________ Bronchitis ❏❏❏ Integumentary Emphysema ❏❏❏ Eczema ❏❏❏ other __________________________ Rosacea ❏❏❏ Psoriasis ❏❏❏ Are you pregnant?❏❏ For how long? _________________________________ other _______________________________

What MEDICATIONS do you take (and how often). If you cannot remember the name of a medication, please just list what it is taken for. Don’t forget over-the-counter medications, vitamins, and home remedies ________________________________________________________

KNOWN ALLERGIES (also specify reaction; e.g., hives, nausea, difficulty breathing, etc.) _____________________________________________ PUPILLARY DILATION is a standard procedure for each comprehensive eye exam. Dilation assists in detection and diagnosis of glaucoma, cataracts, retinal and neurological disease and aids in diagnosing some causes of headaches. The effects of dilation are light sensitivity and mild blur. These may last an average of 4 to 5 hours. You will be able to drive home in most cases, but drive carefully. We strongly suggest that you are dilated with each full exam. Please indicate your preference. There is no additional charge for this service. (Pupil dilation is a covered service if you have vision insurance.)

I DO want my eyes dilated. _______ (initial) I DO NOT want dilation. _______ (initial) I would like to reschedule dilation. ______ (initial)

The above information is accurate and complete to the best of my knowledge and is only for use in my treatment and/or processing and billing. I understand that payments for all visits are due and payable at the time of service unless other arrangements have been made, and that fees paid for eye examinations and contact lens fittings/evaluations are non-refundable. Follow-up visits preceding the final prescription release for contacts are free of charge. If my insurance information is unable to be verified or changes after the exam it will be my (the patient) responsiblility to file for proper reimbursment. {management will do our best to assist with this but it is still your responsiblity to know your benefits before the exam}

Responsible Party ___________________________________ (Relationship to Patient) __________ Date _____________

HIPAA/Confidentiality: Our office recognizes its responsibility to maintain and actively protect the privacy of your healthinformation, exam results, and personal information. Federal law requires us to provide you with a copy of our Patient PrivacyNotice, which went into effect April 14, 2003, and to be able to document that it was received by you. Your signature below indicates only that you have been offered this Notice.

X__________________________________________ ________________

Patient or Responsible Party Signature Date *******************************************************************************************************************

Health Insurance:_______________________(often different than vision but helps us find your vision ins.)

Vision Insurance:__________________________

Members Name:___________________________ Relation to Insured:______________

Members ID:______________________________