Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev.

Address:
City:		State/ZipCode	CT MA AL AK AZ AR CA CO DE DC FL GA HI ID IL IN IA KS KY LA ME MD MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX 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
Last 4 Digits of SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer / School Name
Misc/Guardian		Drivers License #

Is the Billing Address Different?

Billing Information

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Copy Address From Above
Address

City	State	ZipCode
	CT MA AL AK AZ AR CA CO DE DC FL GA HI ID IL IN IA KS KY LA ME MD MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None New Insurance AARP Medicare Supplemental Aetna Group Aetna Medicare PPO Anthem Medicare Preferred BC/BS Medicare Blue Cross Blue Shield CHAMPVA Cigna ConnectiCare CTCare Medicare Health New England HPHC Medicaid Medicare Group Multiplan/PHCS OTHER Out Of Pocket Oxford Tricare East Tricare for Life UHC Medicare Advantage UHC Medicare Complete UHC Medicare Supplement United Healthcare VSP Wellcare
Insurance Plan:
Insurance ID:
Insurance Policy Group:

***Please text a photo of the front & back of your primary insurance card to our secure office phone number: 860-386-5159***

Not Primary on Account: Not Primary

Subscriber Information

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
Last 4 digits of SSN:
Employer/School:

Secondary

Insurance Information

Insurance Name:	None New Insurance AARP Medicare Supplemental Aetna Group Aetna Medicare PPO Anthem Medicare Preferred BC/BS Medicare Blue Cross Blue Shield CHAMPVA Cigna ConnectiCare CTCare Medicare Health New England HPHC Medicaid Medicare Group Multiplan/PHCS OTHER Out Of Pocket Oxford Tricare East Tricare for Life UHC Medicare Advantage UHC Medicare Complete UHC Medicare Supplement United Healthcare VSP Wellcare
Insurance Plan:
Insurance ID:
Insurance Policy Group:

***Please text a photo of the front & back of your primary insurance card to our secure office phone number: 860-386-5159***

Not Primary on Account: Not Primary

Subscriber Information

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
Last 4 Digits of SSN:
Employer/School:

Vision Plan

Insurance Information

Insurance Name:	None New Insurance AARP Medicare Supplemental Aetna Group Aetna Medicare PPO Anthem Medicare Preferred BC/BS Medicare Blue Cross Blue Shield CHAMPVA Cigna ConnectiCare CTCare Medicare Health New England HPHC Medicaid Medicare Group Multiplan/PHCS OTHER Out Of Pocket Oxford Tricare East Tricare for Life UHC Medicare Advantage UHC Medicare Complete UHC Medicare Supplement United Healthcare VSP Wellcare
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Subscriber Information

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
Last 4 Digits of SSN:
Employer/School:

Chief Complaint

Chief Complaint

Secondary Complaint

**Please bring in all current glasses & sunglasses to your appointment**

Glasses History

	No Prior RX
	Glasses Lost
	Glasses Broken
	Scratched
	Did Not Bring Glasses
	History Progressive Non Adapt
	Current RX Working Well

Type

	SV Distance Only
	SV Reading Only
	Lined Bifocal
	Lined Trifocal
	Progressive

Contact Lens History

Last Worn Contact Lens	never today days weeks months years Other
Interest in trying

**If you wear contacts, please wear them in the exam**

History

Patient Ocular History

Select no for all

Condition	Yes	NO
Glaucoma
Glaucoma Suspect
Macular Degeneration
Retinal Disease/Retinal Detachment
Cataract
Lazy Eye/Amblyopia
Vision Loss
Crossed Eyes/Strabismus
Dryness
Color Blindness
Double Vision
Floaters
Flashes

Other Patient Ocular Conditions

Eye Surgeries

Eye Injuries

Medications - No Current Medications

Allergies - No Known Drug Allergies

Patient Surgical History

Psychiatric:	none ADHD anxiety depression special needs Other
Neurological:	none dizziness headaches motion sickness multiple sclerosis numbness paralysis seizures weakness Other
Race	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Other Race Patient Declined to Specify White Other
Ethnicity	Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other
Preferred Language	English Spanish French Patient Declined to Specify Abkhazian Afar Afrikaans Akan Albanian Amharic Arabic Aragonese Armenian Assamese Avaric Avestan Aymara Azerbaijani Bambara Bashkir Basque Belarusian Bengali Bihari languages Bislama Bokm?l, Norwegian), Norwegian Bokm?l Bosnian Breton Bulgarian Burmese Catalan; Valencian Central Khmer Chamorro Chechen Chichewa; Chewa; Nyanja Chinese Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic Chuvash Cornish Corsican Cree Croatian Czech Danish Divehi; Dhivehi; Maldivian Dutch; Flemish Dzongkha Esperanto Estonian Ewe Faroese Fijian Finnish Fulah Gaelic; Scottish Gaelic Galician Ganda Georgian German Greek, Modern (1453-) Guarani Gujarati Haitian; Haitian Creole Hausa Hebrew Herero Hindi Hiri Motu Hungarian Icelandic Ido Igbo Indonesian Interlingua (International Auxiliary Language Association) Interlingue; Occidental Inuktitut Inupiaq Irish Italian Japanese Javanese Kalaallisut; Greenlandic Kannada Kanuri Kashmiri Kazakh Kikuyu; Gikuyu Kinyarwanda Kirghiz; Kyrgyz Komi Kongo Korean Kuanyama; Kwanyama Kurdish Lao Latin Latvian Limburgan; Limburger; Limburgish Lingala Lithuanian Luba-Katanga Luxembourgish; Letzeburgesch Macedonian Malagasy Malay Malay Malayalam Maltese Manx Maori Maori Marathi Marshallese Mongolian Nauru Navajo; Navaho Ndebele, North; North Ndebele Ndebele, South; South Ndebele Ndonga Nepali Northern Sami Norwegian Norwegian Nynorsk; Nynorsk, Norwegian Occitan (post 1500) Ojibwa Oriya Oromo Ossetian; Ossetic Pali Panjabi; Punjabi Persian Polish Portuguese Pushto; Pashto Quechua Romanian; Moldavian), Moldovan Romansh Rundi Russian Samoan Sango Sanskrit Sardinian Serbian Shona Sichuan Yi; Nuosu Sindhi Sinhala; Sinhalese Slovak Slovenian Somali Sotho, Southern Sundanese Swahili Swati Swedish Tagalog Tahitian Tajik Tamil Tatar Telugu Thai Tibetan Tigrinya Tonga (Tonga Islands) Tsonga Tswana Turkish Turkmen Twi Uighur; Uyghur Ukrainian Urdu Uzbek Venda Vietnamese Volap?k Walloon Welsh Western Frisian Wolof Xhosa Yiddish Yoruba Zhuang; Chuang Zulu Other

Height	FT	IN
Weight	LBS

Social History

Smoking Status	Current every day smoker Current some day smoker (not daily) Former smoker (no longer smokes) Heavy smoker (>10 cigs/day) Light smoker (<10 cigs/day) Never smoker (<100 cigs equiv) Smoker (current status unknown) Unknown if ever smoked Other
Alcohol Use	None Social Use Heavy use Alcoholic Recovering Alcoholic Other
Rec/Med Marijuana	None Social Use Heavy use Other

Primary Care Physician
PCO phone #
Other Physicians
Other Physicians Phone #

Family History

Select none for all

Condition	None	Mother	Father	Sibling	Paternal Grandmother	Paternal Grandfather	Maternal Grandmother	Maternal Grandfather
Glaucoma
Macular Degeneration
Retinal Detachment
Cataract
Amblyopia/Strabismus
Blindness

Other Family Ocular Conditions

Family Medical History

Condition	None	Mother	Father	Sibling	Paternal Grandmother	Paternal Grandfather	Maternal Grandmother	Maternal Grandfather
Diabetes
Hypertension
Thyroid
Heart Disease
Cancer

Other Family Medical Conditions - Family History Unknown

Review Of Systems

Allergic/Immunologic:	none allergies hay fever Other	Musculoskeletal:	none muscle/joint pain rheumatoid arthritis swollen joints Fibromyalgia Other
Cardiovascular:	none chest pain circulatory or vascular disease heart problems high blood pressure high cholesterol stroke Other	Constitutional(Current):	none fatigue fever other unexplained weight change Other
Ears, Nose, Throat:	none chronic cough dry mouth runny nose sinus congestion Other	Endocrine:	none diabetes neck pain other glands thyroid Other
Gastrointestinal:	none Other	Genitourinary:	none genitals kidney or bladder problems Other
Integumentary (Skin):	none excessive dryness itching rashes Other	Lymphatic/Hematologic:	none anemia bleeding problems blood disorders Other
Neurological:	none dizziness headaches motion sickness multiple sclerosis numbness paralysis seizures weakness Other	Psychiatric:	none ADHD anxiety depression special needs Other
Respiratory:	none asthma chronic bronchitis coughing emphysema shortness of breath wheezing Other	Cancer:	none Other

Other Patient Medical Conditions

Lifestyle Index

This questionnaire is meant to help your doctor understand what you're experiencing on a regular basis - whether it's caused by your eyes, posture, stress, etc. Your responses will help make sure you recieve the best care possible.

How often do you experience any of these symptoms? Fill in applicable check box.

         *You get headaches of any severity each week (even just a dull ache counts).
         *Your headaches tend to get worse later in the day.

	1	2	3	4	5
Headaches	Never	Rarely	Sometimes	Very Often	Always

Additional Notes:

You experience stiffness/tension in your neck/shoulders when you work at a computer or read (this might even be from your posture).

	1	2	3	4	5
Stiffness/Pain in Neck/Shoulders	Never	Rarely	Sometimes	Very Often	Always

Additional Notes:

Your eyes get tired, burn, or get red easily when you work at a computer for long hours.

	1	2	3	4	5
Discomfort With Computer Use	Never	Rarely	Sometimes	Very Often	Always

Number Of Hours Per Day using A Digital Device: Additional Notes:

Your eyes feel increasingly fatigued/tired as the day goes on.

	1	2	3	4	5
Tired Eyes	Never	Rarely	Sometimes	Very Often	Always

Additional Notes:

Your eyes progressively feel more dry/sandy/gritty while working at the computer or reading.

	1	2	3	4	5
Dry Eye Sensation	Never	Rarely	Sometimes	Very Often	Always

Additional Notes:

Bright / Strong lights (vehicle headlights, florescent lights etc.) bother you.

	1	2	3	4	5
Light Sensitivity	Never	Rarely	Sometimes	Very Often	Always

Additional Notes:

You experience dizziness, motion sickness, or vertigo.

	1	2	3	4	5
Dizziness	Never	Rarely	Sometimes	Very Often	Always

Additional Notes:

Any Additional Notes You'd Like To Add:

Submit Data / Patient Signatures

Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

PATIENT RESPONSIBILITY FORM AND MEDICARE ELIGIBLE PATIENTS ONLY

View PATIENT RESPONSIBILITY FORM AND MEDICARE ELIGIBLE PATIENTS ONLY Form

Print Your Name:
Signature: Date:

Medicare Eligible Patients Only

OPTION 1 - I WANT THE SERVICE LISTED ABOVE. I AM AWARE THAT MY INSURANCE MAY OR MAY NOT COVER THIS LINE ITEM AND I WILL BE RESPONSIBLE FOR THIS AMOUNT IF NOT COVERED BY MY INSURANCE POLICIES.

OPTION 2 - 1 DECLINE THIS SERVICE LISTED ABOVE. I UNDERSTAND WITH THIS CHOICE, I AM NOT RESPONSIBLE FOR THIS PAYMENT AND WILL NOT BE ABLE TO OBTAIN AN UPDATED PRESCRIPTION FOR MY EYE GLASSES UNLESS THIS SERVICE IS PERFORMED.

Initial If Applicable:

Yearly Contact Lens Evaluation - $60.00 Out Of Pocket Expenses

Initial If Applicable:

Routine Or Medical

View Routine Or Medical Form

Routine
Bill Exam To:
Patient Signature:
Date: Time:

Medical
Bill Exam To:
Patient Signature:
Date: Time:

Office use only Based on the preliminary findings of a basic exam, the doctor has determined that the patient has medical issues that need to be addressed. By his or her signature below, the patient has agreed to (a) have the medical issues addressed today and (b) have Connecticut Vision Associates Bill his or her medical insurance instead of a routine vision plan.

Patient Signature: Date: Time:

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT HIPAA - 1996

View HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT HIPAA - 1996 Form

IF THIS POLICY IS NOT ACCEPTABLE TO YOU, PLEASE INDICATE YOUR REASON BELOW:



IF YOU WISH TO ALLOW YOUR PROTECTED HEALTH INFORMATION TO BE SENT AND/OR DISCUSSED WITH ANOTHER PHYSICIAN, RELATIVE OR FAMILY FRIEND, AND/OR ANOTHER THIRD PARTY PROVIDER; PLEASE INDICATE THEIR NAMES BELOW:

OTHER PHYSICIANS:

Name: Phone:

Name: Phone:

Name: Phone:

RELATIVES AND/OR FAMILY FRIEND:

Name: Phone: Relationship:

Name: Phone: Relationship:

Name: Phone: Relationship:

OTHER HEALTHCARE PROVIDERS (THERAPIST, SOCIAL WORKER, ETC):

Name: Title: Phone:

Name: Title: Phone:

Signature Of Patient / Guardian: Date: