Patient information

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Primary Vision Insurance

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Medical History

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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

Vision Therapy History

Medical History

List significant illnesses, bad falls, high fevers or chronic illnesses:

Developmental History:

During pregnancy of this child, did any of the following occur:


My child is:

Skills / Milestones

Has your child undergone any of the following testing / treatment/ therapy?

Visual History

Do you observe or does your child report any of the following?

Strabismus / Amblyopia History

TBI History

What Types Of Professional Care Have You Received or Are Receiving Due To This Injury?

Brain Injury Vision Symptom Survey

Score Each Behavior: Never=0 Seldom=1 Occasionally=2 Frequently=3 Always=4

If you experience any of the symptoms below, please check if the symptom was present before the injury or only after:

Dry Eye History

Over the past week, which of the following eye symptoms have you experienced?

Reading and Computer Symptom Checklist


Please answer the following questions about how your eyes feel when reading or doing close work.

NOTE: if the patient is a child, please read the instructions and then each item exactly as written.

Never=0 Infrequently=1 Sometimes=2 Fairly Often=3 Always=4

Check All That Apply:

Dizziness And Motion Sensitivity Checklist

Policies, Consent, Submit Data

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.