summerlinvision.vegas - Ocular History Form

Date of last eye exam:

Do you currently wear glasses?

YesNo

Do you wear contact lenses?

YesNo

Brand of Contacts

Are you interested in wearing contact lenses?

YesNo

Are you experiencing any of the following ocular symptoms:*

	Yes	No
Blurred Vision
Itching
Burning
Tearing/Watering
Redness
Eye strain/Fatigue
Floaters
Flashes
Double Vision

If you have Blurred Vision

DistanceNear

Please indicate if any of the following conditions apply to you or a family member:*

	Yes	No	Yes	No	Relationship
Cataract
Glaucoma
Macular Degeneration
Retinal Detachment
Blindness
Eye Turn/Lazy Eye

Please list any eye drops you use (prescribed and/or over-thecounter):

Have you ever experienced an injury to an eye?

Please list any surgeries or procedures you have had to your eye(s):

Contact Lens Examination Fees

In order to obtain a valid prescription for contact lenses, a contact lens examination/evaluation must be completed by the optometrist. It is performed every year in order to determine if you have the appropriate lens power and fit, and to ensure your eyes are healthy enough to wear (or continue to wear) contact lenses. The charge for a contact lens fitting may or may not be covered by your vision insurance and such fees will be discussed prior to examination. Medically necessary contact lens fittings are more complex and may require prior authorization from the insurance company. Contact lens fitting fees are payable at the time of service and still apply even if you are unable to successfully wear the lenses.

Please sign and date

Patient Name*

Patient/Guardian signature*

Date*

Traditionally, a retinal examination required dilation of your pupils. Dilation involves placing medicated drops in your eyes to enlarge the pupil size. This allows the doctor to examine the retina at the back of the eye for evidence of ocular disease or manifestations of systemic conditions such as diabetes and hypertension. Side effects from these medications include: sensitivity to light, slight blur of distance vision, and the inability to focus or read up close. These symptoms last approximately 3-4 hours.

Alternatively, we offer digital imaging of the retina. This allows the doctor to evaluate the retina without the effects of dilation and monitor potential changes in retinal structure from year to year. The fee for retinal imaging is $39 in addition to the routine exam fee and is not usually covered by insurance. In certain circumstances, the doctor may still require dilation if she feels signs or symptoms warrant further examination.

Please select one*

I wish to have retinal imaging today ($39)I wish to have my eyes dilated, if necessary

Please sign and date

Patient Name*

Patient/Guardian signature*

Date*

Ocular History

Retinal Imaging