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Demographics


Patient Information Highlighted fields are required.

TitleFirstLastMISuffixNickname
Address: Suite/Apt #:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian



Optical

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
  Last First MI
Name:
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
  Last First MI
Name:
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Child History


-----SECTION 1------PEDIATRIC EYE HEALTH HISTORY------PLEASE COMPLETE FOR YOUR CHILD------------------------------------------------------------------

Child's Full Name: Child's Preferred Name:
Mother/Caretaker's Name: Occupation: Bus. Phone:
Father/Caretaker's Name: Occupation: Bus. Phone:

______________________________________________________________________________________________________________________________________________________
MEDICAL HISTORY:

Pediatrician's Name: Is your child especially afraid of Doctors: YesNo
Last Visit Date: For What Reason? Is your child generally healthy?
Medications (including vitamins & supplements):
Allergies to Medications:
______________________________________________________________________________________________________________________________________________________

List significant illnesses, bad falls, high fevers or chronic illnesses:
Event/Condition...Age...Severity...Complications:
Event/Conditions...Age...Severity...Complications:
______________________________________________________________________________________________________________________________________________________

Neuro/psych eval: YesNo By Whom?
Occupational Therapy eval? YesNo By Whom?
______________________________________________________________________________________________________________________________________________________

Poor Vision: Child Family If Family, who?
Strabismus:Child Family If Family, who?
Amblyopia:Child Family If Family, who?
Cancer:Child Family If Family, who?
Epilepsy/Seizures:Child Family If Family, who?
Learning issue:Child Family If Family, who?
Blindness:Child Family If Family, who?

Other: ______________________________________________________________________________________________________________________________________________________

MED HX / SYSTEM REVIEW:

NOTICE OR COMPLAINS OF:   DOES CHILD HAVE OR HAD:
Eye turns in / out:YesNo***    Eye injury or surgery:YesNo***
Squints / Blinks a lot:YesNo    Lazy eye / Amblyopia:YesNo***
Covers / Closes one eye:YesNo    Patching:YesNo***
Lacks interest in looking at objects:YesNo***    Vision Therapy / Orthoptics:YesNo***
Rubs eyes excessively:YesNo    Surgery / Hospitalizations:YesNo
Reddened or encrusted eyelids:YesNo    Breathing problems:YesNo
Eyelid Droops:YesNo    Gastrointestinal problems:YesNo
Poor tracking / eye movements:YesNo    Musculoskeletal problems:YesNo
Head tilt / Face turn:YesNo    Neurological problems:YesNo
Stumbles over objects / clumsy:YesNo    Development delayed:YesNo
Poor motor control:YesNo    Ear / Nose / Throat problems:YesNo
Head injury / trauma:YesNo

*** If yes, please complete Strabismus/Amblyopia section under the Additional Info tab.

______________________________________________________________________________________________________________________________________________________
DEVELOPMENTAL HISTORY:

Length of Pregnancy: Type of delivery: Forceps / Vacuum Anesthesia

During pregnancy of this child, did any of the following occur:
toxemia trauma use of alcohol
injury by fall smoking use of drugs
severe illness prescription medication little obstetrical care
other
Please explain:






Child's birthweight:lbs. and oz.
Apgar score:@ birth after 10 minutes
My child is:
biological
adopted      At what age?
foster
other      Explain:

______________________________________________________________________________________________________________________________________________________
SKILLS / MILESTONES:

GROSS MOTOR
ACTIVITY AVERAGE AGE YOUR CHILD
Rolled over 3.5 months
Sits w/out support 6.5 months
Walks unaided / alone 12 months
Kicks a ball 18 months
Toilet trained 24 months
Rides tricycle 3 years

FINE MOTOR
ACTIVITY AVERAGE AGE YOUR CHILD
Reaches / grasp for object 4 months
Scribbles spontaneously 15 months
Stacks / Piles blocks 18 months
Eats with a fork/spoon 3 years

LANGUAGE
ACTIVITY AVERAGE AGE YOUR CHILD
Smiles spontaneously 1 month
Says single words 12 months
Refers to self by first name 18 months
Knows full name 3 years

How is your child performing compared to others his/her age:
How well developed is your child's spoken vocabulary?

Has your child undergone any of the following testing/treatment/therapy?
Educational:YesNo Neurological:YesNo Psychological:YesNo
Occupational:YesNo Speech / Auditory:YesNo Physical:YesNo

If yes, please list all previous evaluations done on your child:


Current grade in school: School:
What is their favorite subject?

______________________________________________________________________________________________________________________________________________________
VISUAL HISTORY:

Main reason for having an examination today:
Date of last evaluation: Doctor's name: Pharmacy:
Reason for examination:
Were glasses, contact lenses or other optical devices recommended? If yes, are they used? If yes, when?
If no, why not?
Results / Recommendations:

Do you observe or does your child report any of the following?
HeadachesBlurred Vision
Double VisionEyes "hurt" or "tired"
Nausea when doing visual tasksMotion Sickness / Car Sickness
Bothered by light / sun lightFrequent styes
Eyes itchEyes burn
Eyes tearEyes frequently reddened
Closing or covering one eyeLoses place while reading
Poor reading comprehensionWhen reading, letters/words appear to move or float around
Loses attention easily

Are there any other complaints your child makes concerning vision?

Do you have any other concerns / observations concerning your child's vision?


______________________________________________________________________________________________________________________________________________________

Were you referred to our office? Whom may we thank for this referral?
Referral address: Phone:
If not referred, how did you hear about us?


----- SECTION 6 ------ READING AND COMPUTER SYMPTOM CHECKLIST ----------------------------------------------------------------------------------------

CONVERGENCE INSUFFICIENCY SYMPTOM SURVEY (CISS)
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.
If the patient responds with "yes" please qualify with frequency choices. Do not give examples.

Points: Never =0 Infrequently=1 Sometimes=2 Fairly Often=3 Always=4
1. Do your eyes feel tired when reading or doing close work?
2. Do your eyes feel uncomfortable when reading or doing close work?
3. Do you have headaches when reading or doing close work?
4. Do you feel sleepy when reading or doing close work?
5. Do you lose concentration when reading or doing close work?
6. Do you have trouble remembering what you have read?
7. Do you have double vision when reading or doing close work?
8. Do you see the words move, jump, swim or appear to float on the page when reading or doing close work?
9. Do you feel like you read slowly?
10. Do your eyes ever hurt when reading or doing close work?
11. Do your eyes ever feel sore when reading or doing close work?
12. Do you feel a "pulling" feeling around your eyes when reading or doing close work?
13. Do you notice the words blurring or coming in and out of focus when reading or doing close work?
14. Do you lose your place when reading or doing close work?
15. Do you have to reread the same line of words when reading?

NOTE: For children a score of 16 or more indicates the need for a binocular vision evaluation. For adults a score of 21 does.

In addition:
Check all that apply:
Reverses or forgets letters, numbers or words
Tendency to close or sover one eye
Confuses similar looking words
Head tilt or movement
Difficulty recognizing the same word in the next paragraph
Poor reading comprehension
Poor spelling
Head too close to the paper while reading or writing
Poor visual-motor (eye-hand/foot) coordination
Difficulty tracking moving objects, balls, etc...
Confuses right and left
Writing is crooked or poorly spaced
Difficulty following a sequence of directions
Misalignment of digits or columns of numbers
Whispers when reading silently
Errors copying from chalkboard, computer or book
Comprehension decreases over time
Avoids near work or reading
Does not visualize
Difficulty completing assignments in the time allotted





Adult History


-----SECTION 3--------ADULT EYE HEALTH HISTORY -------------------------------------------------------------------------------------------------------

When was your last eye exam: Where:
Who is your Primary Care Physician:
Pharmacy:

Do you have any MEDICATION ALLERGIES?

Please list all MEDICATIONS you currently use (including over the counter, eye drops and supplements):

List all EYE SURGERIES or INJURIES:


Have you been diagnosed with any of the following EYE CONDITIONS (check all that apply)?
Blindness Corneal Dystrophy Thyroid Eye Disease Cataract
Eye / Eyelid Cancer Macular Degeneration Implant Lens Right Eye Strabismus / Wandering Eye ** if yes, complete strabismus section under Additional Info tab
Retinal Detachment Implant Lens Left Eye Hypertensive Retinal Disease Amblyopia / Lazy Eye ** if yes, complete Strabismus/Amblyopia section under Additional Info tab
Dry Eye Syndrome Diabetic Retinal Disease Glaucoma

Other Eye Conditions:

Check any of the following symptoms you experience:
Eye Pain Flashes of Light Change in Distance Vision Dryness or Burning in Eyes**
Light Sensitivity Change in Near Vision New Spots or Floaters Sandy or Gritty Feeling**
Fluctuating Vision Eye Itching Excess Tearing
Double Vision Mucus Discharge or Crusted Lids Loss of Side Vision   **If yes to above, complete dry eye section under Additional Info tab

Eye Strain with Reading or Computer Work
If yes, complete reading/computer tab

Dizziness or Car Sickness
If yes, complete dizziness/motion sensitivity tab.

Other Eye Symptoms:


VISION HISTORY
What is your primary Vision Correction?
Have you ever worn Contact Lenses? Are you interested in Contact Lenses? Are you interested in Laser Vision Correction?
If yes, please bring your current prescription information with you

Are your Contact Lenses comfortable and working well for you?
Do you have additional glasses? (back up, reading, computer, sun, music, etc)
What is your primary occupation?
How many hours per day do you work on a computer?
List your hobbies or other activities:

CURRENT GENERAL HEALTH HISTORY
Do any of the following conditions apply to you?
Allergy / Hayfever Rheumatoid Arthritis Herpes Zoster Asthma HIV Skin Rashes
Thyroid Disease Hepatitis Sinus Problems Cancer Headaches Seizures
Depression Migraines Multiple Sclerosis High Blood Pressure Diabetes (insulin dependent) Parkinson's Disease
Low Blood Pressure Diabetes (non-insulin dependent) Alzheimer's Disease Head Injury (including Whiplash) - complete brain injury tab High Cholesterol Stroke


Currently Pregnant
List any other conditions (such as Autism, Down Syndrome, ADD/ADHD, Hearing impaired, Speech impaired, Anxiety disorder etc...)


Do you use any of the following:
Alcohol Tobacco Recreational Drugs

FAMILY HISTORY
Is there a history of any of the following conditions in your immediate family?
Glaucoma Rheumatoid Arthritis Diabetes
Retinal Disease Retinal Detachment Crossed or Wandering Eye
Macular Degeneration Albinism Amblyopia / Lazy Eye

Other Family History of Eye Conditions:

______________________________________________________________________________________________________________________________________________________

Were you referred to our office? Whom may we thank for this referral?
Referral address: Phone:
If not referred, how did you hear about us?




Additional Info


-----SECTION 2-----STRABISMUS / AMBLYOPIA HISTORY ----------------------------------------------------------------------------------------------------

(for children and adults with a lazy eye, eye turn or crossed or wandering eye)

At what age was the eye turn first noticed? Did it start suddenly or gradually?

Which direction does the eye turn (check all that apply)?
Up Down Out In

Which eye turns?
Right Left Both

Is the eye turn getting worse, better or no change?
When does the eye turn (always, what % of time, when tired, when ill, etc)?

Does the eye turn more when looking:
up down
to the right to the left
up close in the distance

Do you ever notice one or both eyes shaking rapidly?

If patching treatment was prescribed, please describe at what age patching was started,
how it was done, the eye patched, for how long, and an estimate of the results.


Has there been any surgery? If yes, estimate the results:

Please describe any visual therapy, including duration of treatment, age at which it was started and estimate the results:



-----SECTION 4--------BRAIN INJURY -------------------------------------------------------------------------------------------------------------------

(Stroke, Head injury, Concussion, Whiplash, Motor Vehicle Accident, Bike Accident, Brain Surgery, etc...)

Date of most recent event:

Briefly describe the injury:

What part of the head was affected: Face Top of head Back of head Left side Right side Forehead

Was there loss of consciousness? For how long?
When did you first see a doctor regarding your accident/injury?
Where you hospitalized?

Describe any previous injuries and dates:


WHAT TYPES OF PROFESSIONAL CARE HAVE YOU RECEIVED OR ARE RECEIVING DUE TO THIS INJURY?

(List care such as neurological, psychological, occupational therapy, physical therapy, speech, auditory, chiro, osteopathic, acupuncture, neurofeedback)


What is your most significant visual concern at this time?


####### B I V S S ######### (Brain Injury Vision Symptom Survey) #############################################################

Score each behavior: Never=0 Seldom=1 Occasionally=2 Frequently=3 Always=4

EYESIGHT CLARITY
Distance vision blurred and not clear -- even with lenses
Near vision blurred and not clear -- even with lenses
Clarity of vision changes or fluctuates during the day
Poor night vision / can't see well to drive at night

VISUAL COMFORT
Eye discomfort / sore eyes / eyestrain
Headaches or dizziness after using eyes
Eye fatigue / very tired after using eyes all day
Feel "pulling" around eyes

DOUBLING
Double vision -- especially when tired
Have to close or cover one eye to see clearly
Print moves in and out of focus when reading

LIGHT SENSITIVITY
Normal indoor lighting is uncomfortable
Outdoor light too bright -- have to use sunglasses
Indoors fluorescent light is bothersome or annoying

DRY EYES
Eyes feel "dry" and sting
"Stare" into space without blinking
Have to rub the eyes a lot

DEPTH PERCEPTION
Clumsiness / misjudge where objects really are
Lack of confidence walking / missing steps / stumbling
Poor handwriting (spacing, size, legibility)

PERIPHERAL VISION
Side vision distorted / objects move or change position
What looks straight ahead -- isn't always straight ahead
Avoid crowds / can't tolerate "visually busy" places

READING
Short attention span / easily distracted when reading
Difficulty / slowness with reading and writing
Poor reading comprehension / can't remember what was read
Confusion of words / skip words when reading
Lose place / have to use finger not to lose place when reading


If you experience any of the symptoms below, please check if the symptom was present before the injury, only after or both.
BeforeAfter
Dizziness or motion sickness
Dislike heights
Difficulty understanding what is seen
Difficulty using both sides of the body together
Difficulty recognizing words
Memory problems
Difficulty recognizing faces
Difficulty focusing one or both eyes
Difficulty remembering names of objects
Frequent squinting or blinking
Difficulty remembering people's names
Vision appears unstable or shifts from eye to eye
Unusual head tilt or turn
Difficulty with time management
Portions of a page or objects appear to be missing
BeforeAfter
Difficulty finding objects when grouped together
People or things suddenly appear unexpectedly from one side
Patterned wallpaper or carpets are bothersome
Awkward or poor balance
Looking to the side of objects to see them better
Ears ringing / Tinnitus
Tunnel vision
Confusion / Disorientation
Difficulty concentrating on visual tasks
Gets lost often
Difficulty maintaining eye contact
Bothered by noises
One eye turns in, out, up or down
Bothered by touch
Flashes of light























What activities can you no longer engage in due to your accident / injury?



----- SECTION 5 ------ DRY EYE HISTORY ---------------------------------------------------------------------------------------------------------------

Over the past week, which of the following eye symptoms have you experienced?
Glare Eye ache Night Driving Problems
Redness Burning Eye lids swollen or red along the lash margin
Tearing / Watery eyes Stinging Artificial Tear drops help but do not last long enough
Dryness Dry Mouth Mattering on your eyelids when you wake up in the morning
Light Sensitivity Itching Decreased contact lens wearing time
Burning in the morning Grittiness Vision fluctuates from clear to blurry especially in the morning, after reading, watching TV, computer use or driving.

Do you take Omega-3 supplements daily?
Do you use Visine or other "get the red out" drops? How often?
Have you ever been prescribed RESTASIS eye drops?


----- SECTION 7 ----- DIZZINESS AND MOTION SENSITIVITY CHECKLIST -------------------------------------------------------------------------------------

(Dizziness, Motion Sickness, Car Sickness, etc)
Check all of the symptoms that are significant for you:
Nausea, headache or dizziness when reading in the car even on a STRAIGHT road
Nausea, headache or dizziness when sitting close to a movie screen or watching a train go by
Hyper-sensitive to light (store lights seem bright, tend to wear sunglasses even on cloudy days)
Frequent, sometimes daily, headache or "pressure" in your head
Nausea, headache, dizziness or spacey feeling when shopping or moving through crowds of people
Unusual fear of heights
Lose your place easily when reading
Flickering lights bother you (light through trees when driving or fluorescents)
Avoidance of driving because of car sickness



Policies, Consent and Submit Data


NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.


OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. In the event we make a material change in our privacy practices, we will change this Notice and provide it to you. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to an optician, ophthalmologist or other healthcare provider providing treatment to you for: a) the provision, coordination, or management of health care and related services by health care providers; (b) consultation between health care providers relating to a patient; (c) the referral of a patient for health care from one health care provider to another; or (d) recall information.

Payment: We may use and disclose your health information to obtain payment for services we provide to you. This may include: (a) billing and collection activities and related data processing; (b) actions by a health plan or insurer to obtain premiums or to determine or fulfill its responsibilities for coverage and provision of benefits under its health plan or insurance agreement, determinations of eligibility or coverage, adjudication or subrogation of health benefit claims; (c) medical necessity and appropriateness of care reviews, utilization review activities; and (d) disclosure to consumer reporting agencies of information relating to collection of premiums or reimbursement.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include things such as quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

Marketing Health Products or Services: We will not use your health information for marketing communications without your prior written authorization. We may provide you with information regarding products or services that we offer related to your health care needs. We will never sell your health information without your prior authorization.

To You, Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so or, if you are not able to agree, if it is necessary in our professional judgment.

Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Required by Law: We may use or disclose your health information when we are required to do so by law, including judicial and administrative proceedings.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders and Treatment Alternatives: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters) or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

PATIENT RIGHTS

Access: You have the right to review or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations, where you have provided an authorization and certain other activities, for the last 6 years, but not for disclosure made prior to April14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request in writing that we communicate with you about your health information by alternative means or to alternative locations. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our a Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Dr. Ilana Gelfond-Polnariev
Telephone: 718-481-2020
Address: 4300 Hylan Blvd, Suite 1BC, Staten Island, NY 10312

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