Please Fill Out The Form Below
EYE-DEAL VISION - Dr Thomas Vielma
PLEASE SUBMIT ALL DATA AT THE END OF FORM
General Information
Title
First
Last
MI
Suffix
Nickname
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
Address:
City:
State/ZipCode
TX
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
UT
VT
VI
VA
WA
WV
WI
WY
Home Phone:
Work Phone:
Other Phone:
Alerts:
Cell Phone:
Preferred Contact Method:
Home Phone
Work Phone
Cell Phone
Other Phone
Text Message
Email
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Single
Married
Separated
Divorced
Widowed
Unknown
Employer/School Name
Primary Doctor
No Doctor Assigned
Dr. Vielma, Thomas
Dr. Dr Ptak, Frank
Dr Chawla, Zehra
Misc/Guardian
Billing Information
Is The Billing Address the Same?
Yes If not, please complete address below:
Title
First
Last
MI
Suffix
Mr.
Mrs.
Ms.
Dr.
Rev.
Fr.
Miss
Address
City
State
ZipCode
TX
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
UT
VT
VI
VA
WA
WV
WI
WY
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:
*None
20% DISCOUNT
AARP
ACCESS PREMIER
ACCESSS PLAN B
ACE (9674680)
ACE 9674680
ACE HARDWARE CORPO
Advantica
AEETNA ONE DISCOUN
AETN EXAM ONLY
AETNA
AETNA 100.00 ALLOW
AETNA AHF - EXAM O
AETNA AHF EXAM ONL
AETNA EXAM ONLY
AETNA EXAM ONLY -
AETNA EXAM ONLY -P
AETNA EXAM ONLY PP
AETNA EXAM ONLYPPO
AETNA HMO MEDICARE
AETNA ONE DISCOUNT
AETNA PPO
AETNA PPO $100 ALL
AETNA PPO $200 ALL
AETNA SELECT
AETNA SELECT DISCO
AETNA VISION DISCO
AETNA VISION ONE
AETNA VISION ONE D
AETNA X ONLY-PPO
AFFIL FACI (966185
AHM SERVICING INC
AIG- MONITRONICS
AIG-AVAYA 9728395
AIG-AVAYA REPRESEN
AIG-HERTZ 9718925
AIG-MONITRONICS
AIG 9656695
AIG GROUP DIVISION
AIG GROUP VISION
AIG MONITRONICS
ALLOWANCE 40346
ALLOWANCE PLAN
ALPHASTAFF 9679978
AMERICAN EAGLE (92
APPLE TEXAS RESTAU
AT&T CINGULAR VISI
AT&T SELECT
AT&T VISION PLAN
AT&T VISION PLAN 0
ATAT 9727181
ATT VISION PLAN 00
AUTONATION INC
AUTONATION INC.
AVAYA REP. 9703208
BANK 9657321
BANK 9678004
BANK 9726423
BANK AMER. 9678004
BANK FO AMERICA CO
BANK OF AMERICA
BANK OF AMERICA C
BANK OF AMERICA CO
BCBS
BENEFIT ALLIANCE
BLUE CROSS BLUE S.
BLUE CROSS BLUE SH
BLUE VIEW NATIONAL
BLUE VIEW VISION
BLUECROSSBLUESHEIL
BLUESCOPE STEEL EX
CARDINAL 9700550
CAREMARK RX. L.L.C
CARMAX 9713793
CHASE (9657321)
CHASE 9657321
CHASE BANK 9657321
CHIOCE PLAN
CHOIC- EX ALLOW
CHOIC EX + ALLOW
CHOICE EXAM+
CHOICE PLAN
CHOICE PLUS
CIGNA
CIGNA INTERNATIONA
CIGNA VISION DISCT
CIGNA VISION DIST.
CINGULAR 9727215
CINTAS CORPORATION
COMP BENEFITS
CONCENTRA 9662008
CRAFTMADE/WOODARD
DALLAS AREA RAPID
DARD. REST. 970362
DARDEN 9703620
DARDEN 9703620
DARDEN REST9703620
DARDEN RESTAURANTS
DEN.SEL.-9702895
DENTAL SELECT
DENTAL SELECT-VIS6
DESIGNATED CHOICE
DESIGNTAED CHOICE
DISCOUNT
DISCOUNT (46543)
DISCOUNT 20%
DISCOUNT 46543
DISCOUNT 9238536
DISCOUNT PLAN
DON HERRING AUTO G
DPSG VISION PLAN
DPSG VISION PLAN (
EDS 9699943
EQUIFAX
ERIKS USA 9721986
EXAM ONLY
EXAM ONLY (40381)
EXAM ONLY (40480)
EXAM ONLY 40381
EXAM ONLY 40480
EXAM ONLY 40828
EXAM ONLY PPO 4048
EXAM ONLYPPO 40480
EXAM PLUS
EXAM PLUS ALLOW.
EXAM PLUS DISCOUNT
EXAM PLUS ONLY
EXAM PLUS WITH ALL
EXAM W/ALLOWANCE
EXAMPLUS
EXAMPLUS ALLOWANCE
EXAMPLUS W/ ALLOW
EXAMPLUS W/ALLOW.
EXAMPLUS/ ALLOWANC
EXAMPLUS/ ALLOWENC
EYE.SELECT 9653197
EYEMED
EYEMED 9726423
EYEMED ACCESS
EYEMED PREMIRE
EYEMED SELECT
EYEMED SELECT PREM
EYEMED VISION ONE
EYMED ACCESS
EYMED SELECT PREMI
FIREMAN'S FUND
FM GLOBAL 9688052
FR.LAY. (9686023)
FRITO-LAY 9686023
FRITO-LAY INC.
FRITO LAY
FRITO LAY 9686023
FRTO-LAY, INC.
FUNDED BENEFITS
GAME INC. 9675257
GAMESTOP 9675257
GAMESTOP INC.
GAMESTOP, INC.
GAMESTOP, INC. (96
GENUINE 9660952
GIFT CERTIFICATE
GROUP VISON PS
HAND. INC.#9695214
HANNA ANDERSON
HCA AFFILIATED
HCA AFFILIATED FAC
HCA AFFILIATED FAT
HCA AFFILLIATED FA
HEALTH INC 9658634
HIGHGATE HOTELS L.
HIGHGATE HOTELS LP
HMO
HOSPITALITY MANAGE
HUMAN COMP BENEFIT
HUMANA
ID# MCV00005528280
IKON 9699794
INTERSTATE HOTELS
IRVING ISD
JOHNSON & JOHNSON
JOHNSON AND JOHNSO
JONES DAY
JP MORGAN CHASE
JP PROGRAM
JPG MORGAN CHASE
JPGMORGAN CHASE
JPMORGAN (9657321)
JPMORGAN 9657321
JPMORGAN BANK
JPMORGAN CHASE
JPMORGAN CHASE (96
LANE COMPANY
LENDING PROCESSING
LEVEL 2
LIBERTY 9678756
LIBERTY MUTUAL
LPG MANAGEMENT
LPS MANAGEMENT
LUXOTTICA RETAIL F
MANAGEMENT 9707555
MARRIOTT (9681321)
MARRIOTT VISION PL
MAXIM 9682352
MCLANE 9660705
MED. EYE EXAM
MED. OFFICE VISIT
MED. OV/ SIGNATURE
MED.OFFICE VISIT
MEDICA OFFICE EXAM
Medicaid Traditional
MEDICAL
MEDICAL OFFICE VIS
MEDICAL VISIT
MEDICAL WELLNESS
Medicare
MI PUBLIC SCHOOL E
MICHAELS 9674698
MICHAELS STORES &
MIDWEST NATIONAL L
NATIONAL (9697251)
NATIONAL 9719618
NCH CORP. 9699547
NCH CORPORATION
New Insurance
NONE
NTT AMERICA, INC.
NVA
O2HR, LLC 9727561
OFFICE VISIT
OLDCASTLE (9662552
OLDCASTLE 9662552
OMNICOM GROUP INC
OMNICOM GROUP INC.
ONE DISCOUNT
ONE DISCT
OV/ SIGNATURE
OWENS CORNING (968
PANASONIC CORP OF
PHCS
PITNEY BOWES VOLUN
PLAN 0002 (9727090
PLAN SALUD
PPO
PPO ALLOWANCE
PWH COOP. 9672601
R R DONNELLEY
RACETRAC 9736976
REGINAL NETWORK P
REGIONAL NTWK PL
REGIONAL NTWK PLAN
SABRE HOLDINGS COR
SAFETY EYECARE
SELECT PLAN
SENIOR 9730250
SERVICE MASTER COM
SHER WILL. 9682204
SHER. WILL 9682204
SHERWIN (9682204)
SIGANTURE
SIGHT FOR STUDENTS
SIGINATURE
SIGNARURE
SIGNAT URE
SIGNATRE
SIGNATURE
SIGNATURE CHOICE
SIGNATURE PLAN
SIGNATURE RED CROS
SIGNAUTE
SIGNAUTRE
SIGNAUTRE CHOICE
SIGNITURE
SIGNITURE CHOICE
SIGNTURE
SINGATURE
SINGNATURE
SIX FLAGS 9709122
SIX FLAGS, INC.
SODEXO
SODEXO 9699158
SOLO CUP 9656539
SPECTERA
SPRINT 9729229
SPRINT BY SURENCY
SPRINT SURENCY VIS
SSIGNATURE
STRATEGIC 9670878
STRATEGIC OUTSOURC
SUPERIOR VISION
SUPRE INC.
SURENCY
SURENCY 9729229
SWS GROUP 9670944
TERREMARK WORLDWID
TEXAN PLUS
TEXAS CAPITAL BANK
TEXT. BELL 9681289
TEXTRON 9681289
THE CHEESECAKE FAC
THE HOME DEPOT FT
TJX-9673823 PLAN H
TJX COMPANIES-PLAN
TOMKINS-RUSKIN COM
TOTAL HIGHWAY MAIN
TPG 9717927
TPG HOSPITALITY
TRANSIT (9701137)
TRANSIT 9701137
TX NURSES ASSOCIAT
UHC
UNITEDHEALTH
UNITETE HEALTH CAR
UNIVIEW ACCESS B
Unknown Import
US RENAL CARE, INC
VALASIS
VALASSIS
VALASSIS (9705575)
VALASSIS 9705575
VALSSIS 9705575
VALUE PLAN
VCP
VERIZON (9699695)
VERIZON 9699695
VERIZON COMMUNICAT
VIS.PLAN A 9695271
VISION 1 DISCOUNT
VISION 9681321
VISION CARE
VISION DISCOUNT
VISION ONE 46543
VISION ONE DISCOUN
VISION ONE DISCT
VISION ONE DISCT.
VISION PLUS9727181
VSP
VSP ACCESS PLAN
VSP CERTIFICATE
VSP CHOICE PLAN
VSP GC
VSP SIGNATURE PLA
VSP SIGNATURE PLAN
W158482129
WESCO 9699026
WEST.UNI (9679416)
YUM! BRANDS, INC.
ZACHRY INDUSRIAL
ZACHRY INDUSTRISL
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:
*None
20% DISCOUNT
AARP
ACCESS PREMIER
ACCESSS PLAN B
ACE (9674680)
ACE 9674680
ACE HARDWARE CORPO
Advantica
AEETNA ONE DISCOUN
AETN EXAM ONLY
AETNA
AETNA 100.00 ALLOW
AETNA AHF - EXAM O
AETNA AHF EXAM ONL
AETNA EXAM ONLY
AETNA EXAM ONLY -
AETNA EXAM ONLY -P
AETNA EXAM ONLY PP
AETNA EXAM ONLYPPO
AETNA HMO MEDICARE
AETNA ONE DISCOUNT
AETNA PPO
AETNA PPO $100 ALL
AETNA PPO $200 ALL
AETNA SELECT
AETNA SELECT DISCO
AETNA VISION DISCO
AETNA VISION ONE
AETNA VISION ONE D
AETNA X ONLY-PPO
AFFIL FACI (966185
AHM SERVICING INC
AIG- MONITRONICS
AIG-AVAYA 9728395
AIG-AVAYA REPRESEN
AIG-HERTZ 9718925
AIG-MONITRONICS
AIG 9656695
AIG GROUP DIVISION
AIG GROUP VISION
AIG MONITRONICS
ALLOWANCE 40346
ALLOWANCE PLAN
ALPHASTAFF 9679978
AMERICAN EAGLE (92
APPLE TEXAS RESTAU
AT&T CINGULAR VISI
AT&T SELECT
AT&T VISION PLAN
AT&T VISION PLAN 0
ATAT 9727181
ATT VISION PLAN 00
AUTONATION INC
AUTONATION INC.
AVAYA REP. 9703208
BANK 9657321
BANK 9678004
BANK 9726423
BANK AMER. 9678004
BANK FO AMERICA CO
BANK OF AMERICA
BANK OF AMERICA C
BANK OF AMERICA CO
BCBS
BENEFIT ALLIANCE
BLUE CROSS BLUE S.
BLUE CROSS BLUE SH
BLUE VIEW NATIONAL
BLUE VIEW VISION
BLUECROSSBLUESHEIL
BLUESCOPE STEEL EX
CARDINAL 9700550
CAREMARK RX. L.L.C
CARMAX 9713793
CHASE (9657321)
CHASE 9657321
CHASE BANK 9657321
CHIOCE PLAN
CHOIC- EX ALLOW
CHOIC EX + ALLOW
CHOICE EXAM+
CHOICE PLAN
CHOICE PLUS
CIGNA
CIGNA INTERNATIONA
CIGNA VISION DISCT
CIGNA VISION DIST.
CINGULAR 9727215
CINTAS CORPORATION
COMP BENEFITS
CONCENTRA 9662008
CRAFTMADE/WOODARD
DALLAS AREA RAPID
DARD. REST. 970362
DARDEN 9703620
DARDEN 9703620
DARDEN REST9703620
DARDEN RESTAURANTS
DEN.SEL.-9702895
DENTAL SELECT
DENTAL SELECT-VIS6
DESIGNATED CHOICE
DESIGNTAED CHOICE
DISCOUNT
DISCOUNT (46543)
DISCOUNT 20%
DISCOUNT 46543
DISCOUNT 9238536
DISCOUNT PLAN
DON HERRING AUTO G
DPSG VISION PLAN
DPSG VISION PLAN (
EDS 9699943
EQUIFAX
ERIKS USA 9721986
EXAM ONLY
EXAM ONLY (40381)
EXAM ONLY (40480)
EXAM ONLY 40381
EXAM ONLY 40480
EXAM ONLY 40828
EXAM ONLY PPO 4048
EXAM ONLYPPO 40480
EXAM PLUS
EXAM PLUS ALLOW.
EXAM PLUS DISCOUNT
EXAM PLUS ONLY
EXAM PLUS WITH ALL
EXAM W/ALLOWANCE
EXAMPLUS
EXAMPLUS ALLOWANCE
EXAMPLUS W/ ALLOW
EXAMPLUS W/ALLOW.
EXAMPLUS/ ALLOWANC
EXAMPLUS/ ALLOWENC
EYE.SELECT 9653197
EYEMED
EYEMED 9726423
EYEMED ACCESS
EYEMED PREMIRE
EYEMED SELECT
EYEMED SELECT PREM
EYEMED VISION ONE
EYMED ACCESS
EYMED SELECT PREMI
FIREMAN'S FUND
FM GLOBAL 9688052
FR.LAY. (9686023)
FRITO-LAY 9686023
FRITO-LAY INC.
FRITO LAY
FRITO LAY 9686023
FRTO-LAY, INC.
FUNDED BENEFITS
GAME INC. 9675257
GAMESTOP 9675257
GAMESTOP INC.
GAMESTOP, INC.
GAMESTOP, INC. (96
GENUINE 9660952
GIFT CERTIFICATE
GROUP VISON PS
HAND. INC.#9695214
HANNA ANDERSON
HCA AFFILIATED
HCA AFFILIATED FAC
HCA AFFILIATED FAT
HCA AFFILLIATED FA
HEALTH INC 9658634
HIGHGATE HOTELS L.
HIGHGATE HOTELS LP
HMO
HOSPITALITY MANAGE
HUMAN COMP BENEFIT
HUMANA
ID# MCV00005528280
IKON 9699794
INTERSTATE HOTELS
IRVING ISD
JOHNSON & JOHNSON
JOHNSON AND JOHNSO
JONES DAY
JP MORGAN CHASE
JP PROGRAM
JPG MORGAN CHASE
JPGMORGAN CHASE
JPMORGAN (9657321)
JPMORGAN 9657321
JPMORGAN BANK
JPMORGAN CHASE
JPMORGAN CHASE (96
LANE COMPANY
LENDING PROCESSING
LEVEL 2
LIBERTY 9678756
LIBERTY MUTUAL
LPG MANAGEMENT
LPS MANAGEMENT
LUXOTTICA RETAIL F
MANAGEMENT 9707555
MARRIOTT (9681321)
MARRIOTT VISION PL
MAXIM 9682352
MCLANE 9660705
MED. EYE EXAM
MED. OFFICE VISIT
MED. OV/ SIGNATURE
MED.OFFICE VISIT
MEDICA OFFICE EXAM
Medicaid Traditional
MEDICAL
MEDICAL OFFICE VIS
MEDICAL VISIT
MEDICAL WELLNESS
Medicare
MI PUBLIC SCHOOL E
MICHAELS 9674698
MICHAELS STORES &
MIDWEST NATIONAL L
NATIONAL (9697251)
NATIONAL 9719618
NCH CORP. 9699547
NCH CORPORATION
New Insurance
NONE
NTT AMERICA, INC.
NVA
O2HR, LLC 9727561
OFFICE VISIT
OLDCASTLE (9662552
OLDCASTLE 9662552
OMNICOM GROUP INC
OMNICOM GROUP INC.
ONE DISCOUNT
ONE DISCT
OV/ SIGNATURE
OWENS CORNING (968
PANASONIC CORP OF
PHCS
PITNEY BOWES VOLUN
PLAN 0002 (9727090
PLAN SALUD
PPO
PPO ALLOWANCE
PWH COOP. 9672601
R R DONNELLEY
RACETRAC 9736976
REGINAL NETWORK P
REGIONAL NTWK PL
REGIONAL NTWK PLAN
SABRE HOLDINGS COR
SAFETY EYECARE
SELECT PLAN
SENIOR 9730250
SERVICE MASTER COM
SHER WILL. 9682204
SHER. WILL 9682204
SHERWIN (9682204)
SIGANTURE
SIGHT FOR STUDENTS
SIGINATURE
SIGNARURE
SIGNAT URE
SIGNATRE
SIGNATURE
SIGNATURE CHOICE
SIGNATURE PLAN
SIGNATURE RED CROS
SIGNAUTE
SIGNAUTRE
SIGNAUTRE CHOICE
SIGNITURE
SIGNITURE CHOICE
SIGNTURE
SINGATURE
SINGNATURE
SIX FLAGS 9709122
SIX FLAGS, INC.
SODEXO
SODEXO 9699158
SOLO CUP 9656539
SPECTERA
SPRINT 9729229
SPRINT BY SURENCY
SPRINT SURENCY VIS
SSIGNATURE
STRATEGIC 9670878
STRATEGIC OUTSOURC
SUPERIOR VISION
SUPRE INC.
SURENCY
SURENCY 9729229
SWS GROUP 9670944
TERREMARK WORLDWID
TEXAN PLUS
TEXAS CAPITAL BANK
TEXT. BELL 9681289
TEXTRON 9681289
THE CHEESECAKE FAC
THE HOME DEPOT FT
TJX-9673823 PLAN H
TJX COMPANIES-PLAN
TOMKINS-RUSKIN COM
TOTAL HIGHWAY MAIN
TPG 9717927
TPG HOSPITALITY
TRANSIT (9701137)
TRANSIT 9701137
TX NURSES ASSOCIAT
UHC
UNITEDHEALTH
UNITETE HEALTH CAR
UNIVIEW ACCESS B
Unknown Import
US RENAL CARE, INC
VALASIS
VALASSIS
VALASSIS (9705575)
VALASSIS 9705575
VALSSIS 9705575
VALUE PLAN
VCP
VERIZON (9699695)
VERIZON 9699695
VERIZON COMMUNICAT
VIS.PLAN A 9695271
VISION 1 DISCOUNT
VISION 9681321
VISION CARE
VISION DISCOUNT
VISION ONE 46543
VISION ONE DISCOUN
VISION ONE DISCT
VISION ONE DISCT.
VISION PLUS9727181
VSP
VSP ACCESS PLAN
VSP CERTIFICATE
VSP CHOICE PLAN
VSP GC
VSP SIGNATURE PLA
VSP SIGNATURE PLAN
W158482129
WESCO 9699026
WEST.UNI (9679416)
YUM! BRANDS, INC.
ZACHRY INDUSRIAL
ZACHRY INDUSTRISL
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?
Occasionally
Driving
Reading / Computer
After contact lens removal
1-2 times per week
Half time
Sports
Weekends
Social activities
I currently wear contacts:
Full-time
Part-time If part-time, how often/when?
Occasionally
Driving
1-2 times per week
Half time
Sports
Weekends
Social activities
Contact Lens Wearers: Are your lenses comfortable?
Yes
No
Current Contact Lens Brand:
Acuvue 1-day
Acuvue 1-day Moist
Acuvue 1-day Trueye
Acuvue 2
Acuvue Oasys
Acuvue Oasys for Astigmatism
Acuvue Oasys for Presbyopia
Acuvue Advance
Acuvue Advance for Astigmatism
Air Optix
Air Optix Night & Day
Air Optix Astigmatism
Air Optix Multifocal
Avaira
Biomedic Toric
Biomedic XC
Biofinity
Biofinity Toric
Biofinity Multifocal
Clearsight 1 day
Clearsight 1 day Toric
Focus Dailies Standard
Focus Dailies AC plus
Focus Dailies Toric
Frequency 55
Frequency 55 Toric
Frequency 55 Aspheric
Freshlook colorblends
Proclear
Proclear 1 day
Proclear EP
Proclear Multifocal
Purevision
Purevision 2
Purevision 2 Toric
Purevision Multifocal
Soflens 38
Soflens Toric
Soflens Daily Disposable
Soflens Multifocal
Synergeyes
Vertex Toric
Boston EO
Boston ES
Boston XO
Fluoroperm 60
Menicon Z Thin
RGP - unknown material
Type of Contacts?
Soft
Rigid Gas Permeable
How old is your current pair?
new
1-2 weeks
2-4 weeks
2-3 months
very old
What solution do you use?
None
Unknown
Optifree Pure Moist
Optifree Replenish
Optifree Express
Renu
Biotrue
Clear Care
Generic store brand
Boston original
Boston Simplus
Boston Advance
What is your replacement schedule?
1-Day
2 Weeks
Monthly
2-3 Months
If they feel bad
Quarterly
Yearly
Please list all eyedrops you use (OTC and Rx):
How often used?:
daily
occasionally
rarely
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?
<2 hours
2 - 4 hours
5 - 8 hours
9 - 12 hours
12+ hours
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
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Cancer
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Blindness
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Diabetes
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Eye turn (Strabismus)
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
High Blood Pressure
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Lazy Eye (Amblyopia)
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Stroke
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Glaucoma
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Thyroid Disease
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Cataracts
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Other Inherited Disease
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
Macular Degeneration
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
If Other, what disease?
Retinal Detachment/Disease
Mother
Father
Sister
Brother
Aunt
Uncle
Grandmother
Grandfather
SOCIAL HISTORY (strictly confidential *Required)
How often do you smoke/use tobacco products?
Never smoker
Current everyday smoker
Current someday smoker
Former smoker
Smoker, current status unknown
Unknown if ever smoked
How often do you consume alcohol:
Never
Occasionally
Daily
Do you have?
Hepatitis
HIV
STDs
NONE
Height: Ft
In
Weight
Race:
(Declined)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Ethnicity:
(Declined)
Hispanic or Latino
Not Hispanic or Latino
Prefered Language:
(Declined)
English
Spanish
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
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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