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RAINBOW OPTOMETRY

Please provide as much information as possible.

Patient Information

Patient's last name: First: MI: Nickname: Dr. Miss  
Mr. Mrs. Ms.
Social Security no.: Birth date: Age: Sex: Marital status (select one):
M F
Street address:
City: State: Zip Code: Driver's license: Email address:
Cell phone number: Home phone number: Work phone number:
 
Race: Ethnicity: Preferred Language:  
 
Referred to office by (please select one):  
Full names of other family members seen here:  
                   

Insurance Information

Vision Insurance
Is this patient covered by vision insurance? Yes No
Insurance name: Member ID:  
Patient is not the primary subscriber
Patient's relationship to subscriber:  
Primary subscriber's name: Birth date: Sex: Subscriber's SSN: Home phone number:
M F
Address (if different):  
City:   State:   Zip Code:      
Medical Insurance
Is this patient covered by medical insurance? Yes No
Insurance name: Member ID: Group ID:
Patient is not the primary subscriber
Patient's relationship to subscriber:  
Primary subscriber's name: Birth date: Sex: Subscriber's SSN: Home phone number:
M F
Address (if different):  
City:   State:   Zip Code:      

HEALTH HISTORY QUESTIONNAIRE

Ocular History

In the box below, describe any vision complaints you are currently having such as:

  • Blurry vision at distance or near, difficulty with night driving, glare/light sensitivity
  • Headaches, eyestrain, difficulty focusing
  • Flashes of light or dark sports/squiggles/webs, floaters
  • Glasses lost or broken
  • Dryness, itchiness, tired eyes, burning, redness, pain, sandy feeling , sensitivity to light, excessive tearing , crusting or mucus discharge
  • Check here if you are coming for your annual eye exam only with no complaints.
Current occupation:
You may choose more than one option. Simply select another to add additional occupations.
Select "Other" to enter a specific occupation.
Select [Clear] to start over.
Hobbies/interests:
You may choose more than one option. Simply select another to add additional hobby/interest.
Select "Other" to enter a specific hobby/interest.
Select [Clear] to start over.
How much time do you spend driving? (Select one)
None Not much Average need A lot during the day A lot at night A lot day and night
 
How many hours per day do you typically spend doing the following activities?
  • Watching TV (on a conventional television set)?    
  • Using a desktop computer?    
  • Using a laptop?    
  • Using a tablet/IPad/e-Reader?    
  • Using a cell phone?    
  • Reading books, magazines, and other printed material or doing paperwork?    
 
List any major eye diseases, injuries, infections, surgeries or other significant eye problems and approximate dates:     None
List all Rx and over-the-counter eye medications you currently use:    None
Approximately when was your last eye exam?   
Last eye doctor:   
 
Family Ocular History: Does any family member have any of the following eye conditions? Select all that apply.    None
You may choose more than one option. Simply select another to add additional history.
Select "Other" to enter a specific history.
Select [Clear] to start over.
 

Glasses

Do you primarily wear glasses or contacts? Glasses Contacts Both None
What type of glasses do you primarily wear?
What type of contacts do you wear? Soft contact lenses Soft multifocal contact lenses
  Hard contact lenses Hard multifocal contact lenses
Do you wear computer glasses? Yes No
Do you wear safety glasses? Yes No
Do you wear reading glasses? Custom-made reading glasses Over-the-counter readers None
Do you wear sunglasses? (check all that apply) Prescription Polarized Tinted None
If you are not currectly a contact lens wearer, are you interested in contact lenses? Yes No
If yes, what do you intend to use the contact lenses for? For everyday use For going out For sports
Are you interested in any of the following specialty services that we provide? LASIK Myopic Control None
  Specialty contact lenses for Keratoconus condition
  Specialty contact lenses for post-surgical corneas
       

Contact Lens Wearers Only

What type of contact lenses do you wear? daily disposable 2-week disposable
  monthly disposable yearly replacement lenses
What brand do you wear?
Which disinfecting solution do you use?
How long do you usually wear your lenses per day?
How often do you replace your lenses?
         

Medical History

Primary Care Physician or Other Physician:
Physician's phone number:   Approximately when was your last visit? 

Review of Systems

Have you experienced or been treated for any of the following conditions? (Select all that apply)
Ear, Nose, Throat
You may choose more than one option. Simply select another to add additional condition.
Select "Other" to enter a specific condition.
Select [Clear] to start over.
Cardiovascular
You may choose more than one option. Simply select another to add additional condition.
Select "Other" to enter a specific condition.
Select [Clear] to start over.
Respiratory
You may choose more than one option. Simply select another to add additional condition.
Select "Other" to enter a specific condition.
Select [Clear] to start over.
Genital, Kidney, Bladder
You may choose more than one option. Simply select another to add additional condition.
Select "Other" to enter a specific condition.
Select [Clear] to start over.
Gastrointestinal
You may choose more than one option. Simply select another to add additional condition.
Select "Other" to enter a specific condition.
Select [Clear] to start over.
Endocrine
You may choose more than one option. Simply select another to add additional condition.
Select "Other" to enter a specific condition.
Select [Clear] to start over.
Muscles, Bones, Joints
You may choose more than one option. Simply select another to add additional condition.
Select "Other" to enter a specific condition.
Select [Clear] to start over.
Skin
You may choose more than one option. Simply select another to add additional condition.
Select "Other" to enter a specific condition.
Select [Clear] to start over.
Neurological
You may choose more than one option. Simply select another to add additional condition.
Select "Other" to enter a specific condition.
Select [Clear] to start over.
Psychiatric
You may choose more than one option. Simply select another to add additional condition.
Select "Other" to enter a specific condition.
Select [Clear] to start over.
Blood/Lymph
You may choose more than one option. Simply select another to add additional condition.
Select "Other" to enter a specific condition.
Select [Clear] to start over.
Allergy/Immune
You may choose more than one option. Simply select another to add additional condition.
Select "Other" to enter a specific condition.
Select [Clear] to start over.
Cancer
You may choose more than one option. Simply select another to add additional condition.
Select "Other" to enter a specific condition.
Select [Clear] to start over.
Others
You may choose more than one option. Simply select another to add additional condition.
Select "Other" to enter a specific condition.
Select [Clear] to start over.
       
List ALL injuries or surgeries.    None
List ALL medications and over-the-counter drugs, such as vitamins and inhalers you are currently taking.     None
List ALL allergies to medications.     None
       
Height: Weight:  lbs Are you pregnant or nursing?
Smoking History (select one):
Family Medical History: Does any family member have any of the following conditions?     None   Unknown Family History
You may choose more than one option. Simply select another to add additional condition.
Select "Other" to enter a specific condition.
Select [Clear] to start over.
       
(initial) I acknowledge that I have been offered a copy of and have read and understand Rainbow Optometry's Notice of Privacy Practices. Signed On
 
I, the undersigned, certify that I (or my dependent) have insurance coverage with the above insurance and assign directly to Rainbow Optometry Inc. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. By signing this statement, I understand that my vision and/or health insurance coverage is a contract between myself and my insurance company. Although the doctor and staff have made every effort to verify my benefits before my appointment, no guarantee can be made that the information received is accurate since incorrect information maybe provided by my insurance company from time to time. I understand that it is ultimately my responsibility as the patient to understand my vision and/or health insurance coverage as well as handle any charges my plan does not cover.
 
Patient/Guardian signature Signed on
                            (Typing your name is equivalent to an authorized electronic signature.)
     

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