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Patient Information

Title First Last MI Suffix Nickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor

Insurance Information

Insurance Information
Insurance Name:
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




Last Eye Exam:  
Last Eye Doctor:

I currently wear glasses:  Full-time   Part-time

Interested in LASIK?        Yes   No
Interested in Contacts?      Yes   No
I currently wear contacts:  Full-time  Part-time     Current Brand: 

All eyedrops used:                    
List any eye injuries/surgeries: 

PERSONAL HISTORY   Do you have any of the following?
YES NO YES NO
Glaucoma   Diabetes  
Cataracts   High Blood Pressure  
Macular Degeneration   Stroke  
Eye Turn   Thyroid  
Lazy Eye   Cancer  
Retinal Detachment   High Cholesterol  


Alcohol?   

 Family history is unknown/adopted.

 

FAMILY HISTORY  Does anyone in your family have the following? 

Disease/Condition

Yes

No

Glaucoma

Cataracts

Macular Degeneration

Eye turn

Lazy Eye

Retinal Detachment

Diabetes

High Blood Pressure

Stroke

Thyroid Disease

Cancer

Review of Systems


GENERAL: Fever, weight loss, weight gain, fatigue?
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
ENDORCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux

Low Vision Evaluation

DIAGNOSIS VISION GOALS:
REFERRED BY CTVI / CASEWORKER


Patient denies any changes to health or vision since last eye examination
Patient feels that vision has declined since last eye examination
Patient feels that vision has improved since last eye examination

Chronology Of Vision Loss

Subjective severity of vision loss


Living Situation: Lives alone   with family members in a  single   double story home 
Denies  Endorces difficulty with orientation in home enviornment

Reading: able   not able to read with a low vision deice. Last read for enjoyment approximatly prior.

Medications: able   not able to organize, administer, and manage medication.

Mobility

Finances: Manages independently   requires assistance

Television: watches television   does not watch television  
Computer
Lighting
Transportation

Impact Of Vision Loss (per patient report)


Reading Mild Moderate Severe
Family Life Mild Moderate Severe
Distance Mild Moderate Severe
Social Relationships Mild Moderate Severe
Mobility Mild Moderate Severe
School Or Work Mild Moderate Severe
ADLs Mild Moderate Severe
Transportation Mild Moderate Severe


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