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EYE-DEAL VISION - Dr Thomas Vielma

PLEASE SUBMIT ALL DATA AT THE END OF FORM

General Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
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
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?Yes   If not, please complete address below:
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:
Vision Insurances are a wellness benefit when NO medical condition is diagnosed.
Medical Insurances usually cover service if eye, medical condition IS diagnosed. Primary Vision Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, Middle Initial
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:
Vision Insurances are a wellness benefit when NO medical condition is diagnosed.
Medical Insurances usually cover service if eye, medical condition IS diagnosed. Primary Medical Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

VISUAL HISTORY When was your last eye exam?
Reason for visit: 
Associated: Do you have any other symptoms related to this?
Please list any other eye problems or issues:
I currently wear glasses:   Full-time  Part-time    If part-time, how often/when?
I currently wear contacts: Full-time  Part-time    If part-time, how often/when?
            Contact Lens Wearers: Are your lenses comfortable? Yes No
            Current Contact Lens Brand:
            Type of Contacts? Soft Rigid Gas Permeable 
            How old is your current pair? 
            What solution do you use?   What is your replacement schedule? 
            Please list all eyedrops you use (OTC and Rx): 
            How often used?: 
 
Do you have a history of any of the following?                          Are you currently experiencing any of the following?
SET ALL TO NO YES NO
Blindness
Eye Turn (Strabismus)
Lazy Eye (Amblyopia)
Keratoconus
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment
    SET ALL TO NO YES NO        YES NO
                 Headaches Eyes itch
Blurred Vision Eyes burn
Double Vision Eyes tear
Eyes "hurt" or "tired" Eyes feel dry
Halos around lights Eyes feel sandy/gritty
Bothered by light / sun light Flashing lights
Frequent styes Floaters
Eyes frequently red





  

      
  
     

 
Other eye disease or condition:
Describe any eye injuries:        
List any eye surgeries:             

How many hours a day do you use a computer?
Describe any visual symptoms from computer use: 
MEDICAL HISTORY / REVIEW OF SYSTEMS Physician's Name:       Last Visit Date:
List all medications you are currently taking (including any OTC/vitamins): No Meds

Drug Allergies: No Drug Allergies

Are you pregnant or nursing? Yes  No       If yes, what is the due/birth date?
Do you have, or ever had, any CHRONIC problems in the following areas?
SET ALL TO NO YES NO
Migraines
Multiple Sclerosis
Diabetes
Thyroid problems
Arthritis
Allergies/Hay fever
Asthma
Emphysema
High blood pressure
Stroke
High Cholesterol
Cancer
    
Please list any additional problems:
FAMILY HISTORY Family history is unknown/adopted
Any history of the following in any family members (parents, grandparents, siblings, children)? 
SET ALL TO NO Yes No Relationship to Patient Yes No Relationship to Patient
Poor Vision Cancer
Blindness Diabetes
Eye turn (Strabismus) High Blood Pressure
Lazy Eye (Amblyopia) Stroke
Glaucoma Thyroid Disease
Cataracts Other Inherited Disease
Macular Degeneration If Other, what disease?
Retinal Detachment/Disease
SOCIAL HISTORY (strictly confidential *Required) How often do you smoke/use tobacco products?
How often do you consume alcohol:
Do you have? Hepatitis HIV STDs NONE
Height: Ft  In    Weight 
Race:  Ethnicity:  Prefered Language:
Occupation:   Employer:  
Who may we thank for referring you to our office? If it's a person, please provide their name:
If not referred, how did you hear about Vielma Vision Eye Care?

Office Forms

PLEASE REVIEW THE FORMS BELOW You agree that by checking the box and entering initials, you are providing your consent to the use of the Electronic Document and such election constitutes your electronic signature and consent, and you agree to be bound by the terms and conditions in such Electronic Documents to the same extent as you had signed a paper document.

View NOTICE OF PRIVACY PRACTICES FORM
I have read and understood the NOTICE OF PRIVACY PRACTICES Form. *Required

View HIPAA FORM
I have read and understood the HIPAA privacy act supplemental form. *Required
I hereby give permission/consent to Dr. Vielma, Dr Ptak, or Dr. Chawla to discuss any and all vision treatments with the named individuals below.
      Name  Name  Name 
I do not wish Dr. Vielma, Dr Ptak, or Dr. Chawla to discuss any of my vision treatments with anyone other than me.

Signature: (Print Name) Date *Required

ITEMS TO BRING WITH YOU
  • Insurance Cards (Medical/Vision)
  • Driver License
  • Clear Glasses
  • Prescription Sunglasses