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13695 Colorado Boulevard Thornton, CO 80602
Office (303) 450-2020
Fax (303) 920-1440

Please Fill out the Form Below and Submit at Bottom of Page

Demographics

Title:First:Last:MI:Suffix:Nickname:
Address:
City: State/ZipCode:
Who Referred You? How did you hear about us?
Home Phone: Work Phone:
Other Phone: Misc/Guardian:
Cell Phone: Preferred Contact Method:
SSN: Email:
Birthday: Occupation:
Sex: Male Female Employment Status: Employed Full-Time Student Part-Time Student
Marital Status: Employer/School Name:
Billing Information Is The Billing Address the Same?
Title:First:Last:MI:Suffix:
Address:

City:State:ZipCode:
Home Phone:
Work Phone:

Visual History


VISUAL NEEDS HISTORY
Date Nickname
Last Eye Exam Age
Insurance #1 Insurance #2
Location of Last Eye Exam: Hobbies
Race Preferred Language
Physician's Name: Preferred Pharmacy


Glasses Pair 1:
Glasses Pair 2:
Glasses Pair 3:
Glasses Pair 4:
Glasses Pair 5:
Glasses Prescription Up To Date?




MEDICAL EYE HISTORY

No Changes To Medical History

Have You Been Diagnosed With Any Of The Following Conditions?

Eye Turn (Strabismus): Keratoconus: Low Macular Pigment Density (MPOD): Diabetic Retinopathy: Blepharitis:
Amblyopia (Lazy Eye): Retinal Hole: Epiretinal Membrane: Hypertensive Retinopathy: Melbomian Gland Dysfunction (MGD):
Cataracts: Retinal Detachment: Lattice Degeneration: Iritis / Uveitis / Iridocyclitis: Stye / Hordeolum:
Glaucoma: Macular Degeneration: Posterior Vitreous Detachment (PVD): Preseptal / Orbital Cellulitis: Dry Eye Disease:


Have You Experienced Any Of The Following Symptoms In The Last 30 Days?

Blurred Vision At Distance: Itchy Eyes:
Tired Eyes (Eye Fatigue): Halos Around Lights:
Double Vision: Dry, Gritty, Or Burning Sensation:
Glare At Nighttime:


Do You Have History Of Any Of The Following Eye Treatments Or Therapies?

Vision Therapy: Ortho-K / CRT Contacts:
Myopia Management: Blue Light Blocking Lenses:
Punctal Plugs / Punctal Occlusion: Zeaxanthin / Lutein Supplementation:
LipiFlow: Fish Oil / OMEGA-3 Supplementation:


Have You Had Any Of The Following Eye Surgeries Performed?

Cataract Surgery: Corneal Transplant: Trabeculoplasty:
LASIK: Corneal Cross-Linking (CXL): Glaucoma Laser Procedure (SLT/ALT):
PRK: Retinal Laser: Iris Laser:
RK: Avastin / Lucentis Injections: Blepharoplasty:


Eye Disease Not Listed:
Eye Surgeries Not Listed:
Eye Injuries:
Other Notes On Visual History:

Medical History


PERSONAL MEDICAL HISTORY Last Health Exam:

Medication Allergies:

No Known Drug Allergies

Current Medications Drops (Prescription or Over The Counter): Taken For (Reason/Disease/Condition):
No Current Medications

REVIEW OF SYSTEMS

Please Select "Other" To Type Multiple Answers Or Your Own Text.

Height (ft): (inch)
Weight (lb):

Tetanus Shot Current? Yes No
Pregnant Or Nursing? Yes No Due Date:


Kids - Birth/Dvpmt Hx:  
General:  
Ears, Nose, Throat: Yes No
Cardiovascular: Yes No HTN?
Respiratory: Yes No
Genital, Kidney, Bladder: Yes No
Muscles, Bones, Joints: Yes No
Gastrointestinal: Yes No
Skin: Yes No
Neurological: Yes No
Psychiatric: Yes No
Endocrine: Yes No Diabetes? Type: Last A1C?
Blood/Lymph: Yes No High Cholesterol?
Allergic/Immunologic: Yes No
Other Condition(s): Yes No

Family Medical History

Please Select "Other" To Type Multiple Answers Or Your Own Text.

Adopted: Family History Unknown
Blindness: Cataracts:
Diabetes: Eye Turn (Strabismus):
Lazy Eye (Amblyopia): Glaucoma:
High Blood Pressure: Macular Degeneration:
Other Disease:
Social History
Smoking Status
Discussed Cessation?
Do You Drink Alcohol?
EYE COMFORT QUESTIONNAIRE
1. during a typical day in the past month, how often did your eyes feel discomfort?
0 Never
1 Rarely
2 Sometimes
3 Frequently
4 Constantly

2. When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed?
0 Never Have It
1 Not At All Intense
2
3
4
5 Very Intense

3. During a typical day in the past month, how often did your eyes feel dry?
0 Never
1 Rarely
2 Sometimes
3 Frequently
4 Constantly

4. When your eyes felt dry, how intense was this feeling of dryness at the end of the day, within two hours of going to bed?
0 Never Have It
1 Not At All Intense
2
3
4
5 Very Intense

5. During a typical day in the past month, how often did your eyes look or feel excessively watery? s
0 Never
1 Rarely
2 Sometime
3 Frequently
4 Constantly

Patient Signatures / Submit Data


Please take time to read the following forms! Your signature here is equivalent to physically signing our office forms.

Preventative Eye Health Screenings

View Prevenative Eye Health Screenings


Patient Signature: Date:


Notice Of Privacy Practices

View Notice Of Privacy Practices


Patient Signature: Date:


Financial Policy

View Financial Policy


Patient Signature: Date:


Clean Practice Protocol Patient Agreement

View Clean Practice Protocol Patient Agreement


Patient Signature: Date:


PLEASE REVIEW ALL DATA BEFORE HITTING THE SUBMIT BUTTON




You Do Not Need to Print Forms.