Mr.
Mr.
Dr.
Mrs.
Ms.
Last Name
First
Middle Initial
Address
Apt#
City
State
Zip
Birth date
/
Month
/
Day
Year
Date
Age
Cell:
Home:
Work:
Select what applies to you
Male
Student
Single
Female
Retired
Married
Full Time
Not Employed
Other(Marital status)
Part Time
Spouse's name
Patient Occupation
Patient
Email address
example@example.com
We thank our patients in a special way when they refer us new patients. Whom may we thank for sending you here? Relative/Friend's Name
Did you find us by the insurance portal or looking up our location?
Insurance
Location
VISION INSURANCE
Vision Insurance Co.
Primary Subscriber
Relationship to primary subscribers
Self
Spouse
Child
Subscriber's Birth date
/
Month
/
Day
Year
Date
SECONDARY VISION INSURANCE (IF APPLICABLE)
Vision Insurance Co.
Primary Subscriber
Relationship to primary subscribers
Self
Spouse
Child
Subscriber's Birth date
/
Month
/
Day
Year
Date
I authorize the doctor to release any information including the diagnosis and the records of any treatment or examination rendered to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the doctor or doctor's group insurance benefits otherwise payable to me. I understand that I am responsible for all services or materials whether or not covered by my insurance and that payment is due when services are rendered.
Date
/
Month
/
Day
Year
Date
How long has it been since your last eye exam
years.
your answer
months.
Are you currently having any of the following vision problems? If yes, Please check box
Dry/gritty eyes
Double vision
Light sensitivity
Pain in the eyes
Blurred Vision
Frequent headaches
Twitchy eye lids
Tiredness/Sleepiness Eyes
Eye strain
Itchy Or Burning Eyes
Red/ Watery Eye
Other
Which of the following types of glasses or vision aids have you been prescribed?
Clear prescription glasses
Prescription sports goggles
Non-prescription sunglasses
Sun Prescription Glasses
Safety Glasses
Magnifying lenses or loupes
Computer prescription glasses
Contact lenses
Microscopes/Telescopes
How many hours do you spend on a computer per day?
Per Week?
How many hours do you spend watching TV per day?
How Many Hour do you spend in the sun per day?
Regarding your primary prescription glasses, are they:
Scratched, worn, or damaged
Lost
Out of style or no longer pleasing
Doesn't fit well
Uncomfortably heavy
When using the computer, do you separate prescription computer glasses?
Yes
No, I use my regular prescription glasses
No, I don't wear anything
What type of sunglasses are you currently using to protect your eyes from UV radiation from the sun?
Prescription sunglasses
Clip ons
Transition lenses
Non Prescriptions sunglasses
Polarized lenses
Do you have emergency spare glasses should you lose or break your regular glasses?
Yes, with an updated prescription
No, I do not have emergency glasses
Yes, but with an older prescription
Which of the following sun activities do you frequently engage in?
Walking/jogging/hiking
Gardening
Traveling/sightseeing
Driving/Commuting
Sports (Golf, Fishing, Etc)
Other
MEDICAL & OCULAR HEALTH HISTORY
Primary Physician Name
City
Date of last visit
-
Month
-
Day
Year
Date
Have you ever had Eye surgery? if yes, when and why
Do you or your relatives have any of the following diseases which may lead to vision problems?
Self
Relative
Eye infections
Eye allergies
Eye injury
Glaucoma
Cataracts
Strabismus
Dry eye syndrome
Diabetic Retinopathy
Temporary vision loss
Macular Degeneration
Retinal Detachment
Do you or your relative have any of the following diseases which may lead to vision problems?
Self
Relative
Diabetes
Joint/Back Problem
High Blood Preasure
High Cholesterol
Infectious Syphillus/ Herpes/HIV
Autoimmune: Arthritis/Lopus/Cronh's
Skin problems: Cancer/Eczema/Sunburns
Vascular Diseases: Stroke / heart attacks
Please check Yes or No
Do you Smoke?
Yes
No
How much?
Do you drink alcohol?
Yes
No
How much?
Do you take medications
Yes
No
Please list names and how often
Do you use any other substances?
Yes
No
Contact Lens History
Please complete this section if you have worn contact lenses in the past and want to continue wearing them
What type of contact lenses do you have?
One day soft disposable
Weekly soft disposable
Monthly soft disposable
Quarterly soft disposable
Overnight Ortho K corrective lenses
6 months or more soft lenses
Rgp(rigid gas permeable)lenses
How often do you wear your contact lenses (hrs/day at days/week)?
Do you wear your contact lenses overnight?
Yes, Routinely
Sometimes
Never
Are you experiencing any of the following while using contact lenses?
Dryness towards the end of the day
Irritation
Blurriness
Fluctuations in vision
Redness
Tears easily
What is the name of your clenaing/desinfecting solution/ disinfection system?
Acknowledgement of Receipt of Notice of Privacy Practices
I acknowledge that I have received the Notice of Privacy Practices from Crystal Vision Optometry
Signature
Date
/
Month
/
Day
Year
Date
Are you interested in laser vision correction of overnight Ortho-K Correction lenses
Yes
No
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