Please fill out the following form to the best of your ability.

Section 1: Patient Records

Name*: Salutation Last First M.I.

Gender: Male Female

Address Apt. #

City

State

Zip

HM#  

WK#

 Cell#

Date of Birth (mm/dd/yyyy):

Email Address *

Social Security Number (No Dashes):

Name of Guardian (if minor)

Section 2: Insurance

*Must present Vision Insurance Card, Drivers License, and Major Medical Insurance   Card at time of exam in order for us to file your insurance.
Name of Vision Insurance (if applicable)

Insured's First Name: MI: Last:

Insured's Indentification Number:

Group Number:

Insured's Date of Birth (mm/dd/yyyy):

Patient Relationship to Insured: Self Spouse Child Other

Patient Status: Single Married Other

Full Time Student Part Time Student

Major Medical Insurance Plan

Name of your Major Medical Insurance Plan:

Please answer the following information which is located on your Current Insurance Card

Primary Member's First Name

Primary Member's Last Name

Is this a PPO HMO POS Other    

Primary member's Date of Birth

Is the patient the Member, Spouse, Dependent, or Other?

Group Number

Member Id Number

The telephone number that is listed to Verify Benefits and Elgibility for providers to call

Name of your Secondary Sedical Insurance Plan:

Please answer the following information which is located on your Current Insurance Card

Primary Member's First Name

Primary Member's Last Name

Is this a PPO HMO POS Other    

Primary member's Date of Birth

Is the patient the Member, Spouse, Dependent, or Other?

Group Number

Member Id Number

The telephone number that is listed to Verify Benefits and Elgibility for providers to call

Payment is expected at the time services are rendered, including non-covered portions of insurance. Please note: Most insurance policies pay only a portion of your total charges. If you have questions about your coverage, please contact your representative. We do not guarantee the accuracy of benefit information given to us by insurance companies. Please understand that financial responsibility for your account is yours, not your insurance company.

Section 3: Personal Info

Emergency Contact Name Phone #

Referred by (i.e yellow pages, etc)

Referral: Patient Name

Referral: Doctor Name

Employer

Occupation

Section 4: Glasses History

Do you use a computer? Yes No

If so, how many hours per day?

Do you wear sunglasses? Yes No

Do you currently wear glasses? Yes No

Age of current glasses?

Section 5: Contact Lens History

Do you currently wear contact lenses? Yes No

If so, then how long have you worn contact lenses?

If not, then are you interested in trying contact lenses? Yes No

Type and brand of contact lenses worn, if you are new to our practice.

Today's wearing time?

What contact lens solution do you currently use?

Are you allergic to any medications? Yes No
If yes, list names of medications:

Section 6: Social History

Do you drink alcohol? Yes No

Do you smoke? Yes No

Hobbies / Interests:

Section 7: Eye History

I am interested in an exam for:

Date of last eye exam

Please check Yes or No to indicate if you have the following:

Glaucoma

Yes No

Headaches

Yes No

Cataract

Yes No

Color Deficiency

Yes No

Lazy Eye

Yes No

Retinal Detachment

Yes No

Macular Degeneration

Yes No

Epiphora (excess Tearing)

Yes No

Eye Pain or Soreness

Yes No

Foreign Body Sensation

Yes No

Infection of Eye or Lid

Yes No

Itching

Yes No

Mucous Discharge

Yes No

Ptosis (drooping lid)

Yes No

Redness

Yes No

Sandy or Gritty Feeling

Yes No

Strabismus (crossed eye)

Yes No

Distorted Vision (halos)

Yes No

Double Vision

Yes No

Floaters or Spots

Yes No

Glare / Light Sensitivity

Yes No

Tired Eyes

Yes No

Burning

Yes No

Dryness

Yes No

Section 8: General Health Condition

Ears, Nose, Throat Issues

Yes No

Skin (Acne, Rosacea)

Yes No

Cardiovascular (High Blood Pressure)

Yes No

Neurological

Yes No

Endocrine (Diabetes, Thyroid)

Yes No

Psychiatric

Yes No

Respiratory (Asthma)

Yes No

Blood/Lymph

Yes No

Gastrointestinal

Yes No

Seasonal Allergies

Yes No

Muscles, Bones, & Joints Problems

Yes No

Kidney Problems

Yes No

List any surgeries

Date of surgery

List any medications you are currently taking

Section 9: Family History (Specify relationship to you)

Amblyopia (lazy eye)

Blindness

Cataracts

Color Blindness

Glaucoma

Macular Degeneration

Retinal Detachment

Strabismus (eye turn)

Arthritis

Cancer

Diabetes

Heart Disease

Other

Section 10: Personal/Social Information

Please mark yes to any of the following that you enjoy on a regular basis:

Reading

Yes No

Play Cards

Yes No

Dancing

Yes No

Bingo

Yes No

Music

Yes No

Gardening

Yes No

Building Models

Yes No

Sewing

Yes No

Knitting

Yes No

Embroidery

Yes No

Woodworking

Yes No

Puzzles

Yes No

Do you drive at night?

Yes No