New Patient Form

Contact Info

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

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:
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Unknown Single Married Separated Divorced Widowed Child	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Falden, OD, David Dr. Falden, OD FCOVD, Allison	Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

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 Insurance

Insurance Information

Insurance Name:	None Aetna Avesis AvMed / OptiCare BCBS Cigna Comp Benefits / Vision Care Plan Davis Vision EyeMed Humana Medicaid Medicare Part B NVA Primary Plus Spectera / Optum Health Superior Vision Tricare for Life Tricare Prime and Standard United Health Care United Health Care AARP VA VSP / Vision Service Plan
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:
Employer/School:

Medical Insurance

Insurance Information

Insurance Name:	None Aetna Avesis AvMed / OptiCare BCBS Cigna Comp Benefits / Vision Care Plan Davis Vision EyeMed Humana Medicaid Medicare Part B NVA Primary Plus Spectera / Optum Health Superior Vision Tricare for Life Tricare Prime and Standard United Health Care United Health Care AARP VA VSP / Vision Service Plan
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:
Employer/School:

2nd Medical Insurance

Insurance Information

Insurance Name:	None Aetna Avesis AvMed / OptiCare BCBS Cigna Comp Benefits / Vision Care Plan Davis Vision EyeMed Humana Medicaid Medicare Part B NVA Primary Plus Spectera / Optum Health Superior Vision Tricare for Life Tricare Prime and Standard United Health Care United Health Care AARP VA VSP / Vision Service Plan
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:
Employer/School:

Adult Medical History

______________________________________________________________________________________________________________________________________________________
MEDICAL REVIEW OF SYSTEMS (Check means Yes)
______________________________________________________________________________________________________________________________________________________

CONSTITUTIONAL None See Checks
Fever
Weight Loss or Gain
Fatigue

EYES None See Checks
Loss of Vision
Loss of Side Vision
Distorted Vision or Halos
Fluctuating Vision
Flashes
Floaters
Eye Pain or Soreness
Light Sensitivity
Double Vision
Crossing or Drifting of Eyes
Redness
Discharge
Foreign Body Sensation
Sandy or Gritty Feeling
Dryness
Itching
Burning
Excess Tearing/Watering
Glare
Styes
Eyestrain
Ocular Fatigue
Frequent Skipping of Lines/Words
LASIK
Other:

EARS, NOSE, MOUTH, THROAT None See Checks
Hearing Difficulty
Ringing or Vertigo
Sinus Congestion
Runny Nose
Post-Nasal Drip
Nosebleeds
Dry Throat/Mouth
Hoarseness

CARDIOVASCULAR / VASCULAR
None See Checks
Diabetes
Type 1
Type 2
High Blood Pressure
Chest Pain or Palpatations
High Cholesterol



RESPIRATORY (LUNGS/BREATHING) None See Checks
Cough
Shortness of Breath
Wheezing

GASTROINTESTINAL None See Checks
Swallowing Difficulty
Vomiting/Heartburn
Diarrhea/Constipation
Jaundice
Blood in Stools/Black Stools

GENITO-URINARY None See Checks
Urinary Frequency
Urinary Pain or Blood
Females
Currently Pregnant

MUSCULOSKELETAL None See Checks
Joint Pain, Swelling
Redness
Muscle Pain or Cramps

SKIN None See Checks
Rashes or Color Changes
Itching or Dryness
Hair or Nail Changes

NEUROLOGICAL None See Checks
Headaches
Numbness or Tingling
Weakness or Paralysis
Fainting or Blackouts
Slurred Speech

PSYCHIATRIC
Anxiety
Depression
AD(H)D
Bipolar
Other:

ENDOCRINE None See Checks
Heat or Cold Intolerance
Excessive Thirst or Hunger

HEMATOLOGICAL/LYMPHATICS/IMMUNOLOGY None See Checks
Easy Bruising/Bleeding
Blood Transfusions
Swollen Lymph Nodes

______________________________________________________________________________________________________________________________________________________
(Check means Yes) Write None.
Patient Family History and Social History
______________________________________________________________________________________________________________________________________________________
Meds:
None
No known Drug AllergiesNo current Medications

New Medical Diagnoses NA Allergies: No Known Drug Allergies FAMILY HISTORY - If yes, please respond what type of relative (Mother, Grandfather, etc.) Blindness None Other Glaucoma None Other Macular Degeneration None Other Crossed Eyes or Lazy Eye None Other Diabetes None Other High Blood Pressure None Other Thyroid Disease None Other SOCIAL HISTORY Do you smoke? Do you drink alcohol? Do you use IV drugs? How often for each? NA I am: Divorced Widowed Single Married List Hobbies 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

Race

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Other

Ethnicity

Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify Other

Smoking Status

Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other

______________________________________________________________________________________________________________________________________________________
Vision Express - Ponte Vedra Beach, Central Jacksonville, & North Jacksonville, FL - Ph: (904) 686-1386 Fax: (904) 686-1363 www.YourVisionExpress.com

Child History

________________________________________________________________________________________________________________________________________________________
PATIENT INFORMATION:

Preferred Name/Nickname: Occupation/Grade in School:

If patient is a child, please complete:
Mother/Caretaker's Name: Father/Caretaker's Name:
______________________________________________________________________________________________________________________

VISUAL HISTORY
Referred By:

Main reason for having an examination today:


Date of last eye exam:

Eye Doctor's Name:

Place of Last Eye Exam:

Results/Recommendations from last eye exam:



Age when first prescribed glasses:

What type of glasses do you own? (F9 for menu)

Do you wear contact lenses? If yes, type:

Do you have any other concerns or observations concerning your (or your child's) vision? Specific issues you would like addressed:

________________________________________________________________________________________________________________________
SYMPTOMS OF FOCUSING PROBLEMS:
Blurred Vision at Near (Reading)
Blurred Vision at Far Distances
Focus/Clarity goes in and out
Holds reading too close or far
Vision is worse at the end of the day
Falling asleep when reading
Eyes "hurt" and feel tired
Headaches
Difficulty copying from the board
Difficulty seeing details at night (driving)
Squinting
Frequent blinking
Rubs eyes
Watery eyes (eyes tear up)
Glare/Light sensitive

FREQUENCY OF SYMPTOMS AND NOTES:
Focusing Difficulties:


SYMPTOMS OF EYE ALIGNMENT PROBLEMS:
Eye turns in, out, up, down
Closes or covers an eye
Double vision
Words run together when reading
Unable to judge distances
Clumsy/knocks things over
Poor depth perception
Difficulty with 3-D movies
Tilts or turns head to see
Inconsistent sports performance
Eyes drift
Poor eye contact

FREQUENCY OF SYMPTOMS AND NOTES:
Eye alignment difficulties:


________________________________________________________________________________________________________________________
IF YOUR CHILD HAS DIFFICULTY WITH READING OR LEARNING OR SCHOOLWORK IN GENERAL, PLEASE FILL OUT THE REST OF THE FORM. IF NOT, PLEASE SKIP TO THE BOTTOM AND FILL OUT THE GENERAL HEALTH AND REVIEW OF BODY SYSTEMS. ________________________________________________________________________________________________________________________

SYMPTOMS OF TRACKING PROBLEMS:
Moves head when reading
Skipping lines when reading
Rereads words
Repeating lines when reading
Skips small words when reading
Loses place while reading
Uses a finger to keep spot
Poor tracking
Prefers being read to
Avoids reading
Difficulty recognizing the same word
Reading comprehension declines over time
Poor reading comprehension
Remembers what is heard better than what is seen
Can't keep eye on ball
Reads slowly
Words look like they move on the page

FREQUENCY OF SYMPTOMS AND NOTES:
Tracking difficulties
:

VISUAL PROCESSING, VISUAL ATTENTION, VISUAL PERCEPTION SYMPTOMS:
Reverses letters/numbers
Difficulty seeing details
Poor test performance
Confuses letters, words, or numbers
Forgetful, poor memory
Difficulty with puzzles
Misplaces belongings
Confuses left and right
Can't picture things in mind (visualize)
Takes a long time to complete assignments
Loses attention easily

FREQUENCY OF SYMPTOMS AND NOTES:
Visual Processing Difficulties:


POOR EYE-HAND COORDINATION SYMPTOMS
Writes uphill or downhill
Poor writing
Avoids sports
Misaligns columns or math problems
Poor eye-hand coordination
Poor fine-motor: scissors/keys/tools
Writes slowly
Poor large-motor skills: ex. bike riding
Difficulty throwing a ball
Frequent erasing
Difficulty catching a ball

FREQUENCY OF SYMPTOMS AND NOTES:
Eye-Hand Coordination Difficulties:


EYE HEALTH SYMPTOMS
Rubs eyes
Frequent pink eye
Irritated eyes
Reddened or encrusted eyelids
Eyes itch or feel gritty
Bothered by lighting (bright or dim)
Eyes become red or bloodshot
Eyelid droops
Nausea when doing visual tasks
Frequent styes
Eyes sting or burn
Motion or car sickness

FREQUENCY OF SYMPTOMS AND NOTES:
Eye health concerns:


________________________________________________________________________________________________________________________
VISUAL HISTORY:
Do you have any eye problems, or are there any of the following conditions present in the family?
Eye disease (Glaucoma, Cataract, etc.)
Eye injury
Poor Vision
Eye surgery
High prescription glasses or contact lenses
Eye tumor
Blindness
Please describe the details of the condition (who in the family, severity etc.)


Amblyopia (lazy eye)
Amblyopia details (which eye, when diagnosed, family history etc.):


Patching details:

Prior vision therapy or orthoptic treatment details:
_________________________________________________________________________________________________________________
Strabismus (crossed eyes/eyes drift out)
Strabismus details (which eye, what direction):


Is the eye turn related to a trauma, disease, or condition?

Age the eye(s) first began to turn:

What direction does the eye turn?

Does the same eye always turn?

When does the eye turn?

Prior treatments: (surgery, eye drops, patching, glasses, vision therapy etc.)

_________________________________________________________________________________________________________________
GENERAL HEALTH
Medical History (list medical conditions, significant illnesses, bad falls, high fevers, developmental delays or chronic illnesses.)

Medications (include vitamins and supplements) and for what health condition:

Please list any medical conditions that run in your family:

Allergies (include seasonal allergies, food allergies/sensitivities and allergies to medications):


Medical Doctor:

Date and Reason for last doctor's visit:
__________
REVIEW OF BODY SYSTEMS (Please describe specific health problems in the following body systems):
No medical conditions or injuries

General Health (weight loss/fatigue):

Ears, Nose, Throat:

Cardiovascular (heart):

Respiratory (lung):

Gastrointestinal (stomach):

Developmental Delays:

Genital, Kidney, Bladder:

Muscles, Bones, Joints:

Skin (rash):

Neurological:

Psychiatric (anxiety/depression):

Endocrine:

Blood/Lymph:

Allergic/Immunologic:

Learning issue (delay disability):

Trauma/Surgery:
_________________________________________________________________________________________________________________
DEVELOPMENTAL HISTORY (please complete if the patient is an infant or child)

Premature? (under 37 weeks)

Length of Pregnancy:

Type of delivery:

Pregnancy Complications:


Delivery/Neonatal Complications:



Child's birthweight:

Apgar Scores:

My child is: Biological Adopted Foster Other:

Were there any delays in development? (crawling, walking, talking etc.)

_________________________________________________________________________________________________________________
HAS THE PATIENT UNDERGONE ANY OF THE FOLLOWING TESTING, TREATMENT, OR THERAPY?
Educational
Occupational Therapy
Physical Therapy
Psychological
Speech / Auditory
Neurological
Genetic
Other:
IF YES, PLEASE LIST RESULTS AND RECOMMENDATIONS (LENGTH OF THERAPY AND WHEN/HOW OFTEN THERAPY IS/WAS PERFORMED):

Is there any other information you feel would be helpful or important in our treatment? (relationships with peers/adults, reaction to stress, anxiety etc.)

_________________________________________________________________________________________________________________
SCHOOL/WORK HISTORY
Describe any school or work difficulties:

How far away do you sit from the monitor? How many hours a day do you use a computer?

Any tutoring or remedial assistance?

Performing at potential?

Attitude towards school or work?

Attitude towards reading?
________________________________________________________________________________________________________________________
HOBBIES/SPORTS ACTIVITIES
List leisure time activities (hobbies/sports/music/art etc.)

Sports performance: areas excelled in, areas of difficulty

Give a brief description of your child (or self) as a person:

_________________________________________________________________________________________________________________
Notes for the Doctor:

Vision Express Ponte Vedra Beach, Central Jax, & North Jax, FL Ph: (904) 686-1386 Fax: (904) 686-1363 www.YourVisionExpress.com

Submit Info

Please make sure to fill out the Patient Demographics, Insurance and Medical History tabs before clicking the Submit Data button below.