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

Demographics


Patient Information
Title First* Last* MI Suffix Preferred Name
Address*
City St  Zip
Cell Phone*
or Home Phone (optional)
Email*
Preferred Contact By
DOB (mm/dd/yyyy)*  
Sex Female Male Intersex
Occupation | Grade
Employer | School

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.

General Medical History


General Medical History

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

You   Mom Dad  Sib   When were you diagnosed & other pertinent details:
Hypertension
High Cholesterol
Rheumatic Disease
Cancer
Diabetes

If you are diabetic, when were you diagnosed?  
If you are diabetic, what is your A1c level? 
Are you Pregnant or Nursing?  
Smoking Tobacco Status*
Alcohol Use

List any other medical conditions or surgeries (and approximate year of surgery):
List all prescription and over-the-counter medications you currently take:
List any vitamins or supplements you currently take:
List any drug or non drug-related allergies you have:

Please list any problems you are currently having.
For those who are generally healthy, these will likely be left blank:


General   (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain)
Ear, Nose, Throat   (e.g., sinus congestion, dry mouth/throat, sleep apnea, hearing problems)
Cardiovascular   (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIA/stroke)
Respiratory   (e.g., chronic cough, shortness of breath, wheezing)
Genital, Kidney, Bladder   (e.g., urinary problems, discharge, menstrual changes, impotence)
Gastrointestinal   (e.g., constipation, diarrhea, heartburn (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, 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
Corneal Reshaping Therapy (Eliminates daytime glasses/contacts by sleeping in therapeutic contacts)
Scleral Lenses (Provides exceptionally clear/stable vision for high prescriptions or Keratoconus/Pellucid)
Comprehensive Eye Exam w/ Glasses Evaluation
Comprehensive Eye Exam w/ Contact Lens Evaluation
Dry Eye Evaluation

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

You   Mom Dad  Sib   Pertinent Details:
Glaucoma
Macular Degeneration
Retinal problems
High Myopia (>6.00D)
Lazy Eye/Eye Turn


List any current visual problems (blur, tired eyes, headaches/migraines, etc):
List any chronic eye problems or eye surgeries (and approximate date of surgery):
List all eye-related prescription and over-the-counter medications you currently use:
Hours/day spent on the computer, phone, and tablet?

If you wear contact lenses, please fill out the following:

How often do you replace your lenses?
How do your contacts feel in the morning after insertion?
How do your contacts feel at the end of the day prior to removal?



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

Pediatric


Skip this section for patients OVER 17 years of age

Parent or Guardian Information

Title: Mr. Mrs. Ms. Dr.
First Name Last Name

Your Child's Medical History

Does your child have a vitamin D deficiency? Yes No Unsure
Has your child ever had an allergic reaction to atropine? Yes No Unsure
Are there any medical preservatives your child is allergic to? Yes No Unsure

Approximate date of your child's last physical exam?
Approximate date of your child's last eye examination?
Pediatrician contact info (if available):


How many hours per day does your child spend outside, on average? Less Than 2 2-3 More Than 3
Does your child wear eyeglasses, even if part-time? Yes No
     If 'yes' to the above question, when did they start wearing eyeglasses?
Does your child use a computer or digital handheld device? Yes No
     If 'yes' to the above question, how many hours/day? How many days/week

Has your child ever worn contact lenses? Please select all that apply: Soft Daily Disposable Bifocal/Multifocal Soft
Gas Permeable Overnight Soft Orthokeratology

Parent Medical History



Questions for the parents: Mother Father
Currently wear eyeglasses or contact lenses? Yes No Yes No
Any eye surgery, including refractive surgery (LASIK, PRK, etc)? Yes No Yes No
Glasses are worn:
Part-time for distance vision (driving, movies, etc)? Yes No Yes No
Part-time for near vision (reading phone/computer)? Yes No Yes No
Full-time? Yes No Yes No

Age each parent first wore eyeglasses or contact lenses, even if part-time?
Parental Ethnicity (a relationship may exist between certain ethnicities and myopia progression)

Sibling Information

If your child has siblings, please fill out the following:
Brother Age: If they wear eyeglasses or contacts, approximate age when first worn?
Brother Age: If they wear eyeglasses or contacts, approximate age when first worn?
Sister Age: If they wear eyeglasses or contacts, approximate age when first worn?
Sister Age: If they wear eyeglasses or contacts, approximate age when first worn?


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

Ocular Symptoms


Skip this section for patients UNDER 18 years of age OR if you never experience dry eyes
Using the 0-3 scale below, report how often these eye symptoms occur:
  • 0 = Never occurs
  • 1 = Sometimes
  • 2 = Often
  • 3 = Constantly
Dryness, Grittiness, or Scratchiness   
Soreness or Irritation
Burning or Watering
Eye Fatigue

Using a slightly different 0-4 scale, report the severity of the same eye symptoms below:
  • 0 = No problems
  • 1 = Tolerable - not perfect, but not uncomfortable
  • 2 = Uncomfortable - irritating, but does not interfere with my day
  • 3 = Bothersome - irritating and interferes with my day
  • 4 = Interolerable - unable to perform my daily tasks
Dryness, Grittiness, or Scratchiness   
Soreness or Irritation
Burning or Watering
Eye Fatigue
If you suffer from dry eye, list any over-the-counter or prescribed medical treatments that you have used specifically for your dry eye:



Please select the Policies and Submit Data tab at the top to continue filling out your form.

Policies and Submit Data


NOTICE OF PRIVACY PRACTICES

This notice is a summary of our policies protecting your medical information.

It states that we cannot and will not share your medical information without your expressed consent.


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 21, 2016, 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 April 21, 2016. 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.

Contact Person: Eric To
Telephone: 626.921.0199 Fax: 626.921.0195
E-mail: info@lumenoptometric.com
Address: 14 W. Sierra Madre Boulevard, Sierra Madre, CA 91024



Please check, sign, and date that you have read and agree to our policies
and click the SUBMIT button to complete your online forms. Thank you!


Check:
Patient/Guardian Signature:
Date: