Patient Full Name:
*
First & Last
Date:
*
-
Month
-
Day
Year
Date
Address (Street & Mailing):
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone:
*
Please enter a valid phone number.
Home Phone:
Please enter a valid phone number.
Social Security Number:
Sex:
Male
Female
Date of Birth:
*
-
Month
-
Day
Year
Date
Email Address:
example@example.com
Marital Status:
Married
Single
Divorced
Widowed
Employment Status:
Full Time
Part Time
Unemployed
Student
Retired
Employer Name & Address
Business Name
Address
Occupation:
Referred By:
Last Eye Exam Date & Doctor:
Patient/Responsibility Party Name (Address & Phone if different than patient):
Computer/Phone Use?
Yes
No
How Many Hours Per Day?
Do you experience computer/phone eye strain?
Yes
No
Reason for visit today?
Do you have vision insurance?
Yes
No
Insurance Company:
Insured ID #
Group #
Insured Date of Birth
-
Month
-
Day
Year
Date
Insured Place of Employment
Relation to Patient
Do you wear glasses?
Yes
No
How often do you wear glasses?
All the time
Occasionally
Reading
Driving
TV
Other
How old are your glasses?
Have you had problems with glasses in the past?
Are you interested in contact lenses?
Yes
No
Have you ever worn contact lenses?
Yes
No
What type are you wearing?
Hard
Gas Perm
Soft
Disposable
Astigmatism
Bifocal
Monovision
What brand of contacts are you wearing?
How long have you had this pair?
Type of contact solution?
Ever had a reaction to drops or solutions?
Yes
No
List medications you are currently taking - including eye drops, birth control, vitamins, or any non-prescription medications.
If you have a list of medications already recorded, please bring it with you to the office.
List your allergies to medications or other substances.
Physicians name:
Last physical exam:
Eye Health History - Check all that apply.
Bloodshot Eyes
Blurred Vision - Distance
Blurred Vision - Near
Burning Eyes
Cataracts
Color Vision Defect
Crossed Eyes
Discharge from Eyes
Dizzy Spells
Double Vision
Dry Eyes
Eye Infection
Eye Injury
Eye Strain
Fainting Spells / Blackouts
Floaters / Spots
Glaucoma
Headaches
Itching Eyes
Lazy Eye
Light Sensitive
Loss of Vision
Migraine Headaches
Night Vision Poor
Red Eyes
Seeing Halos
Seeing Flashes
Temporary Loss of Vision
Twitching Eyelids
Watering Eyes
General Health & Family History
Check all that apply to yourself and your immediate family history.
Arthritis
Yourself
Family Member
Asthma
Yourself
Family Member
Blindness
Yourself
Family Member
Cancer
Yourself
Family Member
Cataracts
Yourself
Family Member
Diabetes
Yourself
Family Member
Emphysema
Yourself
Family Member
Epilepsy
Yourself
Family Member
Eye Surgery
Yourself
Family Member
Glaucoma
Yourself
Family Member
Hay Fever
Yourself
Family Member
Heart Condition
Yourself
Family Member
Hepatitis
Yourself
Family Member
High Blood Pressure
Yourself
Family Member
High Cholesterol
Yourself
Family Member
Kidney Disease
Yourself
Family Member
Lazy Eye
Yourself
Family Member
Lupus
Yourself
Family Member
Migraine Headaches
Yourself
Family Member
Pacemaker
Yourself
Family Member
Poor Color Vision
Yourself
Family Member
Retinal Disease
Yourself
Family Member
Shingles
Yourself
Family Member
Skin Conditions
yourself
Family Member
Stroke
Yourself
Family Member
Thyroid Disease
Yourself
Family Member
Tuberculosis
Yourself
Family Member
Turned Eyes
Yourself
Family Member
Dilation of Pupils
We may need to dilate your pupils to examine the health of the inside of your eyes. This means you will be given drops that enlarge your pupils (the black circles inside your eyes). This is the best method to thoroughly examine all the structures and tissues inside your eyes. Dilation usually lasts 4 to 6 hours. You may experience some blurring, light sensitivity and difficulty reading during this time. Disposable sun wear is available at no charge.
Office Policies
Payment for exam is expected at the time of service. We accept cash, personal checks, MasterCard, VISA, Discover, and Debit Cards. All glasses and contact lenses must be paid for in full when delivered, unless other arrangements have been made. We guarantee your satisfaction with our services and products.
The information in this document and your file are held confidential.
Patient's Signature
*
The practice:
(a) is required by federal law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing the Practice’s legal duties and privacy practices with respect to your PHI; (b) adheres to Ohio law in those instances where Ohio law does not conflict with federal law. See explanation of Ohio law, attached; (c) is required to abide by the terms of this Privacy Notice; (d) reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains; (e) will distribute any revised Privacy Notice to you prior to implementation; (f) will not retaliate against you for filing a complaint.
EFFECTIVE DATE
This Notice is effective as of 04/15/03.
Patient Acknowledgement
I have been given the right to review such Notice of Privacy Practices prior to signing this consent.
Patient Signature
*
Date
*
-
Month
-
Day
Year
Date
You have my permission to give my health information to:
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