Prosper Family Eyecare


Demographics

General Information
Title
 First
 Last
 MI
 Suffix
 Nickname

Address Line 1:
Line 2:
City:
 State Zip Code
Home Phone:
Email:
Work Phone:
Other Phone:
SSN:
Birthday:
Sex:
 Male Female
Marital Status:
Occupation:
Employment Status:
 Employed Full-Time Student Part-Time Student
Employer/School Name:
Misc/Guardian:
Billing Information
 Is The Billing Address the Same?
Title
 First
 Last
 MI
 Suffix
Address Line 1:
Line 2:
City:
 State Zip Code
Home Phone:
Work Phone:

Insurance 1

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account:
Not Primary
Primary on Account
Name (Last, First, MI):
Relationship to Insured:
 Spouse Child Other
Sex:
 Male Female
Address:
City:
 State: Zip:
Phone Number:
Birthday:
Employer/School:

Insurance 2

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account:
 Not Primary
Primary on Account
Name (Last, First, MI):
Relationship to Insured:
 Spouse Child Other
Sex:
 Male Female
Address:
City:
 State: Zip:
Phone Number:
Birthday:
Employer/School:

Insurance 3

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account:
 Not Primary
Primary on Account
Name (Last, First, MI):
Relationship to Insured:
 Spouse Child Other
Sex:
 Male Female
Address:
City:
 State: Zip:
Phone Number:
Birthday:
Employer/School:

Medical History

Primary Vision Correction
Glasses Contacts Both Glasses and Contacts None
Yes No Do you work at a computer?
    Approximate # of hours per day?
Yes No Do you experience sensitivity to sunlight?
Yes No Do you have prescription sunglasses?
Yes No Do you have difficulty seeing at night?
Yes No Have you noticed any changes in your vision?
    Distance Near Both distance and near
Contact Lenses
Yes No Are you interested in Contact Lenses?
Yes No Have you ever worn Contact Lenses?
    Brand of contacts?
    When was the last time you wore contacts?
    Solution? Optifree Clear Care Complete Renu Generic Boston
    Other:
Yes No Do you have an interest in a "Test Drive" of the latest contact lens design?
PLEASE NOTE: Contact lens evaluations are performed on all contact lens patients. The purpose of the evaluation is to determine the size, material & power of the contacts needed, monitor the effects of the contact lenses on the eyes, determine if changes are needed from year to year, discussion with the doctor regarding contacts, wearing schedules, discard cycles, solutions, power, etc. and includes trials and follow-up visits. The evaluation is required prior to determining or renewing a prescription, is a separate fee and is not included in the examination.
Initials:
Have you ever been diagnosed with the following?
Yes No Glaucoma
Yes No Lazy Eye
Yes No Macular Degeneration
Yes No Retinal Detachment
Yes No Cataracts
Yes No Other:
Yes No Allergies to any medications?
    Please List:
Do you experience the following?
Yes No Burning
Yes No Tearing
Yes No Gritty/Sandy feeling
Yes No Itching
Yes No Floating Spots
Yes No Flashes of Light
Yes No Headaches
Yes No Blurry Vision
Yes No Other:
Is there a family history of:
Yes No Glaucoma
    Who?
Yes No Macular Degeneration
    Who?
Yes No Blindness
    Who?
Yes No Lazy Eye
    Who?
Yes No Retinal Detachment
    Who?
Yes No Other:
Current Eye Medications:
Last Eye Doctor:
Last Eye Examination:
Current Medications:
Primary Care Physician:
Date of last exam/physical:
Phone Number:
Fax Number:
Yes No Are you pregnant or nursing?
Yes No Do you smoke?
less than 1/2 pack per day 1/2 pack per day 1 pack per day more than 1 pack per day
Yes No Do you drink alcohol?
    Occasionally More than 2 glasses per week
Yes No Do you use recreational drugs?
    Please describe:
     
Family Medical History
Yes No Diabetes? Relationship to you?
Yes No Heart Disease? Relationship to you?
Yes No Other:

Review of Systems

Do you currently have any of these problems?
General: Fever, weight loss, weight gain, fatigue?
Ears, Nose, Throat:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genital, Kidney, Bladder:
Muscles, Bones, Joints:
Integumentary (skin/breast):
Neurological:
Psychiatric:
Endocrine:
Blood/Lymph:
Allergic/Immunologic:

Submit

Review

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