Patient Historical Intake

Today’s Date ______/_____/______PRINT CLEARLY IN BLACK INK ONLY

Name______S.S#______

If patient is a child – Parent’s Name______

If patient is a child – name of person accompanying child today and relationship

______

Address______City______State______Zip______

Phone (Home) ______Date of Birth: ______

(Work)______Sex M F

(Cell)______Occupation______

Do you prefer calls at: home work cellphone E-mail

EMAIL - You will receive appointment reminders, order notifications, yearly recalls, eye care news, and special promotions.

Our office uses e-messaging to contact patients. Do you prefer TXT messaging or e-mail? ______

INSURANCE
Vision Insurance______ID#______
Medical Insurance______ID#______
Secondary Medical Insurance: ______ID#______
Insurance Holder______Date of birth______
Relationship to patient ______Phone# ______
Their address: ______
Their social security # :______(required for all patients using insurance as payment)
Does your insurance require you to get a referral for any doctor visits? Yes No
If yes, you need one for your visit today, PRIOR to seeing the doctor.
It is the patient’s responsibility to know what insurance coverage they have. If you are not sure, we suggest you call
your insurance company prior to the examination. The correct insurance information is required on the day of service
and cannot be accepted afterwards.
****WE NEED A COPY OF YOUR INSURANCE CARD & DRIVER’S LICENSE SO PLEASE KEEP IT OUT****
REASONS FOR TODAY’S VISIT: Choose below which applies today from Vision and/or Medical
ANNUAL WELLNESS EXAMINATION (no problems)
VISION RELATED VISIT (check all that apply)
Blurry vision-related problems Contact Lens Services (Annual Evaluation or New Fit) Lasik Consult
Vision-Related Complaints:  Distance vision blurred  Near vision blurred
MEDICAL RELATED VISIT - Medical insurance applies for evaluating symptoms of this nature
check all the medical problems that concern you on a regular basis
 pain in/around eyes or soreness  headaches  burning  redness  double vision
 eye infections  itching  tearing  floaters  foreign body sensation
 light sensitivity  dry eyes  eye strain  watery eyes  styes on lids
 crusting of lashes/lids  flashing lights  halos / spots droopy eyelid  temporary loss of vision
Date of last eye exam______Wear glasses? Yes No Contact Lenses? Yes No
How do you use your glasses? all the time work (safety) computer reading/near work distance only
How old are your glasses? 1 year  2 year Other______
Will you be getting eyeglasses today? Yes No Have a spare pair of glasses? Yes No
MEDICATIONS: ______
______
MEDICATION ALLERGIES: ______

HISTORY OF MEDICAL EYE PROBLEMS:

SELF FAMILY SELF FAMILY

Cataracts Yes No Yes No Eye surgery Yes No

Eye injury Yes No Lasik Yes No

Macular Degeneration Yes No Yes No Blindness Yes  No Yes No

Glaucoma Yes No Yes No Crossed Eyes Yes No Yes No

Lazy eye Yes No Yes No Poor color vision Yes No Yes No

PATIENT’S & IMMEDIATE FAMILIAL MEDICAL HEALTH HISTORY, PAST & PRESENT: Check Yes or No

SELF FAMILY SELF FAMILY

Allergies Yes No Yes No Heart Condition Yes No Yes No

Asthma Yes No Yes No High Blood Pressure Yes No Yes No

Cancer Yes No Yes No HIV +/ AIDS Yes No Yes No

Diabetes Yes No Yes No Hormonal Disorders Yes No Yes No

Epilepsy / Seizures Yes No Yes No Respiratory Disorders Yes No Yes No

Migraine Headaches Yes No Yes No IV Drug Abuse Yes No Yes No

Psychiatric problems Yes No Yes No Skin Disorders Yes No Yes No

Thyroid Problems Yes No Yes No Neurological problems Yes No Yes No

Fever, Weight loss Yes No Ears, Sinus, Throat problems Yes No

Arthritis / Muscular Yes No Yes No Blood Disorders Yes No Yes No

*Kidney Disorders Yes No Yes No Head injury Yes No

*Liver Disease Yes No Yes No Stroke Yes No Yes No

List all MEDICAL CONDITIONS or DISABILITIES that were not listed above: ______

______

Primary Physician______Phone: ______

CONTACT LENS: Are you a contact lens wearer or would like to be one? Yes No No, but would like to be fit

Contact lens wear requires careful monitoring of the user to guarantee long term success. The standard of medical care regarding contact

lenses is to conduct an annual evaluation of the performance of the contact lenses and to evaluate how the ocular physiology has adapted to

contact lens use. Fees for fittings and evaluations are not covered by most insurances. Those new to contact lens wear must go through an

assessment period that requires instruction, fitting and evaluation.

Please see a staff member with any questions on fees.

Do you wear contact lenses? Yes No Former wearer (reason if discontinued) ______

Type of lenses: Soft….Gas Permeable (Hard)…Toric (for astigmatism)… Bifocal…Monovision … Extended Wear

How often are your lenses replaced? One Day 2 Weeks Monthly Annually Sleep in your contact lenses? Yes No

Do you know the brand of your current contact lenses? No Yes ______

SOCIAL HISTORY:

Are you pregnant and / or Nursing?  No  Yes If yes, how many weeks / months along are you?

Do you drink alcohol?  No Yes How often? Social use  1-2 drink daily  Other

Do you use tobacco product?  No  Former user  Yes

How often?  Less than 1pk / day  1-2pk / day  More than 2pk / day

OPTOS…..SCANNING LASER DIGITAL RETINAL IMAGING ……..No More Dilating Drops!!!

As part of our pre-testing process, we perform Optos, ultra-field retinal imaging on all patients. This is important in assisting to detect and measure changes each time you get your eyes examined. Glaucoma, Diabetes, & Macular Degeneration are diagnosed by detecting changes over time. Retinal imaging will be covered by your medical insurance with a medical diagnosis. Those patients with no medical diagnosis who wish to have the doctor discuss the findings and keep it as part of your medical record, the cost is $40.

Scans will only be evaluated upon patient request.

Yes. I am choosing the Optos retinal imaging included in my wellness exam ______(initial)

No. I decline the Optos retinal imaging against the advice of my doctor ______(initial)

I authorize the diagnosis of my ocular health by means of visual fields, photography, pachymetry, or other diagnostic

aids deemed appropriate. I understand that certain procedures may not be covered by my insurance. I have reviewed

the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information

will be used by the doctor to help determine appropriate treatment.

We use “Coordination of Benefits” with your insurances, which means the vision plan may cover some of the fees that

Medical insurance does not cover, such as co-pays and refraction fees.

·  In some cases, we will bill your vision plan first for a routine exam and reappoint you for follow-up medical care which is billed to medical insurance

·  In some cases, such as emergencies, we perform a medical exam and treatment first and then reappoint for a routine exam and refraction.

Payment in full is due the day that services are rendered unless arrangements are made prior to your visit. Fees for

professional services i.e. exams, contact lens fittings are not refundable. I understand that I am financially responsible

for any copays, deductibles, fees for non-covered services, etc. I am responsible for any outstanding balance for

services provided that are not fully covered by my insurance, and may be billed for this remaining balance. I have

provided accurate insurance information.

For your convenience, accepted forms of payment include cash, check, MasterCard, Visa and Discover.

______

Signature (Required every year) Date

*****Complete Both Sides of This Form or The Next Page***** ______reviewed by doctor