Online Patient Forms

Patient information

*This field is required

*This field is required

*This field is required

*This field is required

*This field is required

*This field is required

*This field is required

*This field is required

*This field is required

Primary Vision Insurance

Please choose from the menu options or select the option to type in your own text. Thank you!

Medical History

Please choose from the menu options

Eye History

Contact Lens Wearers only:

Medical History:

Do you have any of these medical conditions?

Family Medical History

Does anyone in your family have any of these medical conditions?







Family Eye History

Does anyone in your family have any of these eye conditions?







Review Of Systems














Social History





Dry Eye Disease

Enviornmental Factors
Systemic Conditions
Systemic Meds
Ocular Meds
Artificial Tears Times/day
Signs
Contact Lenses

Frequency Legend: (rate on a scale of 3: 0 = Never, 1 = Tolerable, 2 = Often, 3 = Consistant)
Severity Legend: (rate on a scale of 4: 0 = No Problems, 1 = Tolerable, 2 = Uncomfortable, 3 = Bothersome, 4 = Intolerable)

Symptoms
Frequency
of Symptoms
Severity
of Symptoms
Symptoms
at This Visit
Symptoms
Within Past
72 Hours
Symptoms
Within Past
3 Months
Dryness, Grittiness, Scratchiness
Yes No
Yes No
Yes No
Soreness or Irritation
Yes No
Yes No
Yes No
Burning or Watering
Yes No
Yes No
Yes No
Eye Fatigue
Yes No
Yes No
Yes No
Fluctuating Vision
Yes No
Yes No
Yes No

OSDI Legend: (rate on a scale of 4: 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Often, 4 = Always)
Experienced In
The Following?		 Limited In Performing
The Following?		 Uncomfortable
In The Following?
Sensitivity To Light? Reading? Windy Conditions?
Gritty Feeling? Driving At Night? Low Humidity?
Painful Or Sore? Computer Use? Air Conditioning?
Blurred Vision? Watching TV? Poor Vision?

Policies, Consent, Submit Data



NOTICE OF PRIVACY PRACTICES
View Notice of Privacy Practices Form



Acknowledgement of Pupil Dilation
Because some medical conditions first show up in the eye, the retina is best viewed with a dilated pupil. The doctors at 20Twenty Eyecare recommend a pupillary dilation once every two years, however, certain medical conditions require a dilated exam more often.

Please talk with our doctors or a staff member if you have any questions.

Please Initial One:



Optomap Retinal Exam
In our continued efforts to bring the most advanced technology to our patients, we are proud to announce the inclusion of the Optomap Retinal Exam as an integral part of your exam today.

Our doctors are concerned about retinal problems including macular degeneration, glaucoma, retina holes or detachments, and systemic diseases such as diabetes, stroke, and high blood pressure. These conditions can lead to serious health problems, including partial loss of vision or blindness, and often develop without warning and progress with no symptoms.

An Optomap Retinal Exam provides:
• An eye wellness scan
• An in-depth view of the retinal layers (where diseases can start)
• The ability for you to view your Optomap image at the time of your exam
• An annual, permanent record of your medical file, which gives doctors
• Comparisons for tracking and diagnosing potential eye disease

Insurance typically does not cover any advanced screening technology beyond the general exam. Our doctors highly recommend the Optomap Retinal Exam for all patients. This will be done as an enhancement to the general eye exam for a fee of $42.00.