Please look through all the tabs and fill out any pertinent information before selecting the submit button on the last tab.


Demographics


Patient Information
TitleFirst*Last*MISuffixPreferred Name
Address*
City St  Zip
Cell Phone*
or Home Phone (optional)
Email*
Preferred Contact By
DOB (mm/dd/yyyy)*  
Sex Female Male
Occupation | Grade
Employer | School
If Minor, Guardian:

How did you find us? Yelp? Google? A friend's recommendation? 


Please select the General Medical History tab at the top to continue filling out your form.

Insurance

Vision Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Please check here if you are not the primary on the account: Not Primary

Please fill in the following information for the Primary Member on the account
Name:Last, First, MI
Patient's relationship to Primary Member:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
* SSN:
Employer/School:

* We are unable to authorize your insurance benefits without this information. Please provide at least the last 4 digits.
Medical Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Please check here if you are not the primary on the account: Not Primary

Please fill in the following information for the Primary Member on the account
Name:Last, First, MI
Patient's relationship to Primary Member:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
* SSN:
Employer/School:

* We are unable to authorize your insurance benefits without this information. Please provide at least the last 4 digits.

General Medical History


General Medical History
Primary physician's name & phone  
When was your last physical exam?

Check the box for any conditions that apply (or leave blank if not applicable):

You   Mom Dad  Sib   No Describe (type, when were you diagnosed, etc)
Hypertension
Thyroid
Cardiovascular
Cancer
Diabetes
If YOU are diabetic, when were you diagnosed?    Last A1C level? 
Are you Pregnant or Nursing?  

List ALL major injuries or surgeries you have had and approx dates:
List any other medical conditions you have had, including non-drug allergies:
List all Rx and over-the-counter medications you currently take:
List any vitamins or supplements you currently take:
List any drug allergies you have:

Smoking Status
Alcohol Use
Do you live alone?  

Review of Systems

Please list any problems you are currently having anywhere, from head to toe:


(leave blank if not applicable)

General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain)
Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, sleep apnea, hearing problems)
Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs)
Respiratory (e.g., chronic cough, shortness of breath, wheezing)
Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge, menstrual changes, impotence)
Gastrointestinal (e.g., constipation, diarrhea, gastric reflux (GERD), jaundice, nausea, vomiting)
Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination)
Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements)
Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration)
Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, dementia, speech problems)
Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive)
Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising)
Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes)



Please select the Ocular History tab at the top to continue filling out your form.

Ocular History


Purpose of Visit & Ocular History
Who was your previous eye doctor?  
When was your last eye exam?

Check the box for any conditions that apply:

You   Mom Dad  Sib   No Describe (type, when diagnosed, which eye(s), treatment,etc)
Glaucoma
Macular Degeneration
Retinal problems
Cataracts
Lazy Eye/Eye Turn

List any major eye injuries, infections or surgeries and approx dates:
List any other significant eye problems you have had:
List all Rx and over-the-counter eye medications you currently use:
List any vision complaints you are currently having such as:
  • blurred vision, headaches, eyestrain, double vision, or losing your place when reading
  • itching, burning, redness, pain, sensitivity to light, watering, crusting or mucus discharge
  • seeing rainbows around white lights at night, flashes of light or dark spots/squiggles/webs

How many hours/day do you spend using the computer, reading books/magazines, and/or playing sports?:

Contact Lens Wearers Only
What disinfecting solution do you use?
How long do you usually wear your lenses?
How often do you replace your lenses?
How old is your current pair of contacts?



Please select the Vision Therapy tab at the top to continue filling out your form.

Vision Therapy


Vision Therapy (leave blank if not applicable)

Grade: School:
Teacher: Subject:
      ADD/ADHD
      Autism
      Learning Disorder
        Other Delays:  
        Therapies:  

Symptom Checklist:

Please check all the symptoms that apply for the patient:

HA
Diplopia
Crossing Eye
Wandering Eye
Lazy Eye
Fatigue/strain w/reading
Other
Letter reversals
Losing place while reading
Omitting small words when reading
Transposing letters/#s (ie 12 for 21)
Dislike reading
Words swim/move/jump
Slow reader
Poor eye hand cord
Can't keep eye on ball
Poor handwriting
Poor memory
Can't visualize
R/L confusion
Difficulty copying from board



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