Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Sex*

M
F

SSN*

Emergency Contact

Emergency Phone

Physician’s Name

Physician’s Phone

Home Phone

Cell Phone*

Work Phone

Email Address

Date

Have you been to our office before?

How did you hear about us?

How can we make your visit the best you’ve ever had?

What sports/hobbies do you enjoy?

How many hours per day are you on the computer?

Reason for today’s visit?

Date of last exam?*

If you don't remember, please enter approximately how long ago like 1 year, 2 years ago, etc.

Contact lens info

Do you currently use contacts?*

Yes
No

What type? (select one in each row)

Age of current contacts?

Are you interested in getting contacts today?

Yes
No

Glasses info

How old are your current glasses?*

Are you interested in getting new glasses/contacts today*

Yes
No

Ocular Health: Questions regarding your eyes.

1. Have your eyes ever been dilated?*

Yes
No

If so, How Long ago?

2. Have you ever had an eye infection, disease, injury, or surgery?*

Yes
No

Explain

3. Are you unusually sensitive to light?*

Yes
No

4. Do you ever see double?*

Yes
No

Explain

5. Do you have trouble with night vision?*

Yes
No

6. Do you have unusually frequent or severe headaches?*

Yes
No

When and Where?

7. Do you have blurred vision?*

Yes
No

When

Do you have any of these dry eye symptoms? (check all that apply)*

Contact lens intolerance
Redness
Itchiness
Stinging
Burning
Tearing
Dryness
Frequent Styes
None of the above

Medical Health Family History: Questions regarding your medical health and family history. Please Check All that apply

Anyone in the family or yourself have been diagnosed with the following in the past or present.

Diabetes Type I*

None
Myself
Father
Mother
Bro
Sis
Other

Specify

Diabetes Type II*

None
Myself
Father
Mother
Bro
Sis
Other

Specify

High Blood Pressure*

None
Myself
Father
Mother
Bro
Sis
Other

Specify

Thyroid Problems*

None
Myself
Father
Mother
Bro
Sis
Other

Specify

Cancer*

None
Myself
Father
Mother
Bro
Sis
Other

Specify

Heart Disease/Attack*

None
Myself
Father
Mother
Bro
Sis
Other

Specify

Kidney Trouble*

None
Myself
Father
Mother
Bro
Sis
Other

Specify

Respiratory Problems*

None
Myself
Father
Mother
Bro
Sis
Other

Specify

Liver Disease*

None
Myself
Father
Mother
Bro
Sis
Other

Specify

Psychiatric Care*

None
Myself
Father
Mother
Bro
Sis
Other

Specify

Hepatitis (A, B, C, D, E)*

None
Myself
Father
Mother
Bro
Sis
Other

Specify

Anemia*

None
Myself
Father
Mother
Bro
Sis
Other

Specify

Fainting/Dizzy Spills*

None
Myself
Father
Mother
Bro
Sis
Other

Specify

Other

Please list any medication allergies*

Please list any other allergies*

Please list any medications you are currently taking and doses*

Social History

Do you drink alcohol ?*

Yes
No

How much?

Do you use tobacco?*

Yes
No

How much?

Do you use any other substances or recreational drugs?*

Yes
No

What?

Financial Agreement

*

I understand that all copayments, deductibles, or charges over the maximum benefit amount allowed by my insurance is due at the time of service.

*

I understand that all charges, regardless of insurance coverage, are ultimately the responsibility of the patient. If for any reason, payment is denied by my listed insurance company, the office will seek payment from me. Any benefits or pre-authorizations are not a guarantee of payment.

*

By signing below, I agree that I am financially responsible for any balance owed that is not covered by insurance. My signature also certifies that the information on this form is true and correct.

Health Information Protection*

I have read and agree to the Privacy Policy

Signature of Patient or Party Responsible

Retinal Photo Consent

We recommend dilation every year with a comprehensive exam, however for patients who do not want to be dilated, photos are recommended.

Dilation:

Pros:: Most comprehensive retinal evaluation. Dilation makes the pupil larger which gives us a better view of the retina. When the eyes are dilated we can see straight back which is where the nerve and macula are as well as far into the periphery of the eye.
Cons:: Dilation causes blurry vision up close for about 2-3 hours. Dilation will also make you light sensitive (we have disposable sunglasses in office to counteract this effect).

Retinal Photos:

Pros:: You get to see inside of your own eye allowing you participate in your own care. There is a permanent record of exactly how your eye looks to compare year to year.
Cons:: We do not see as much area of the retina as with dilation.

PLEASE SELECT ONE OF THE FOLLOWING OPTIONS*

I authorize Advanced Eyecare Solutions to take Retinal photos instead of dilation. I understand there is $40 fee that is not covered by insurance.
I do not want to be dilated today and refuse to get retinal photos taken as an alternative.
I would like to be dilated today for a comprehensive health assessment.

Signature

Contact lens info

Glasses info

Ocular Health: Questions regarding your eyes.

Medical Health Family History: Questions regarding your medical health and family history. Please Check All that apply

Anyone in the family or yourself have been diagnosed with the following in the past or present.

Social History

Financial Agreement

Retinal Photo Consent

Advanced Eyecare Solutions