Patient Information

General Information

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

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:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Bourque, Lori Dr. Ballard, Thomas Dr. House, Provider Dr. Clark, Veurmer Dr. Davis, Nicole Dr. Sukenik, Olga	Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

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:

Medical Insurance

Medical Insurance Information

Insurance Name:	None Aetna Always Vision Care Benefits Avesis Inc. Cigna Open Access Compbenefits Corporation Davis Vision Eye Care For Kids EyeMed Humana-PVC Medicaid Medical Eye Service Medicare Nationwide Vision New Insurance NVA Opticare Vision Plan Optumhealth Vision (Spectera) Principal Life Insurance Co Safehealth life Insurance Company Superior Vision UMR United Health Care Vision Service Plan Wells Fargo 3rd party Adm/godwwin
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:

Vision Insurance Information

Insurance Name:	None Aetna Always Vision Care Benefits Avesis Inc. Cigna Open Access Compbenefits Corporation Davis Vision Eye Care For Kids EyeMed Humana-PVC Medicaid Medical Eye Service Medicare Nationwide Vision New Insurance NVA Opticare Vision Plan Optumhealth Vision (Spectera) Principal Life Insurance Co Safehealth life Insurance Company Superior Vision UMR United Health Care Vision Service Plan Wells Fargo 3rd party Adm/godwwin
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:

Secondary Insurance Information

Insurance Name:	None Aetna Always Vision Care Benefits Avesis Inc. Cigna Open Access Compbenefits Corporation Davis Vision Eye Care For Kids EyeMed Humana-PVC Medicaid Medical Eye Service Medicare Nationwide Vision New Insurance NVA Opticare Vision Plan Optumhealth Vision (Spectera) Principal Life Insurance Co Safehealth life Insurance Company Superior Vision UMR United Health Care Vision Service Plan Wells Fargo 3rd party Adm/godwwin
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:

Please complete the next tab 'Medical and Eye History'

Medical and Eye History

        Whom may we thank for referring you?  Self referral Family friend Coworker Doctor Walk-in Insurance Company Internet search Facebook Twitter YELP Email ad Postcard ad Newspaper ad Radio ad TV ad Other   Referral's Address or Phone Number: 
        If you are a returning patient: Which reminder did you receive?  Email Text Phone None Other

        A. CHIEF VISUAL COMPLAINT

        What Brings You in Today?  Poor Distance Vision Poor near vision Fluctuating vision Double vision Night blindness Loss of side vision Loss of central vision Loss of or very limited Red eye Eye pain Dry eyes Other    Which Eye?:  Right Left Both Other    Symptoms:  None Headaches Yellow Discharge White ropey discharge Watery discharge Itching Red eyes Eye pain/soreness Dry eyes Sandy gritty feeling Flashes of light Floaters Glare/Light sensitivity curtain over eye Other

        Onset:    Meds Used:    CL Wearer:  NO YES Other

        Secondary Complaint:  BLURRY VISION (FAR) BLURRY VISION (NEAR) Wanted to evaluate the visual and health status of the eyes - OU LOST GLASSES BROKEN GLASSES HEADACHES DRY SCHOOL NURSE REFERRAL DPS REFERRAL DIABETIC EYE EXAM FLASHES FLOATERS EXCESSIVE CLOSE WORK BURNING ITCHY OTHER Other   Notes: 

        B. EYE HISTORY

        Last Eye Exam:  cannot remember 1 year 2 years 3 years never years ago Other   Diagnosis:  No Visual problems don't remember Myopia Hyperopia Astigmatism Presbyopia Amblyopia Other   Doctor Prescribed:  Nothing Eyeglasses Contact lenses Prescription sunglasses Computer glasses Safety glasses Sports Glasses Other

        Last Eye Doctor's name:  Don't remember Other    Last Eye Doctor's Address:  Don't remember Other    Last Eye Doctor's Telephone:  Don't remember Other

        Please check all eye conditions that apply to you:  Good Ocular Health Floaters Glaucoma Cataracts Macula degeneration Cataract surgery Strabismus/no surgery Strabismus surgery "Lazy eye" (Amblyopia) Recurrent infections Diabetic retinopathy/laser trmt Diabetic retinopathy/monitering Recurrent hordeolum foreign body history Eye injury w/ vision loss Eye injury w/o vision loss Retinal problem/unknown dx keratoconus Corneal dystrophy Other   Have you ever had any Eye surgeries?  None Lasik OU Blepharoplasty OU Cataract OU Cataract OD Cataract OS Lasik enhance Strabismus Laser Retinal Repair Cryo Retinal Repair Scleral Buckle Lasik PRK PRK enhance YAG Cap Other
        Procedure Date: 

        Family Members with Eye Conditions (blood relatives only)
        My  Mother Father Grandmother Grandfather Brother Sister Other    Has   Myopia Hyperopia Astigmatism Presbyopia Ambloyopia Corneal dystrophy Dry eyes Cataracts Glaucoma Diabetic Retinopathy Hypertensive Retinopathy Crossed/Lazy eye Macular degeneration Eye trauma Other
        My  Mother Father Grandmother Grandfather Brother Sister Other    Has  Myopia Hyperopia Astigmatism Presbyopia Ambloyopia Corneal dystrophy Dry eyes Cataracts Glaucoma Diabetic Retinopathy Hypertensive Retinopathy Crossed/Lazy eye Macular degeneration Eye trauma Other
        My  Mother Father Grandmother Grandfather Brother Sister Other    Has   Myopia Hyperopia Astigmatism Presbyopia Ambloyopia Corneal dystrophy Dry eyes Cataracts Glaucoma Diabetic Retinopathy Hypertensive Retinopathy Crossed/Lazy eye Macular degeneration Eye trauma Other

        C. EYEGLASSES HISTORY  Do You Wear:

Prescription Eyeglasses	Safety Glasses
Prescription Sunglasses	Sports Goggles
Computer eyeglasses

        HOW OLD ARE YOUR CURRENT EYEGLASSES:  N/A 1 Year 2 Years More than 2 years Other

        D. CONTACT LENS HISTORY

        Do you wear contact lenses?  Yes No Both Other   If yes, What Brand?  AirOptix AirOptix for Astigmatism AirOptix for MultiFocal Dailies ACP Acuvue Oasys Acuvue Oasys for Astigmatism 1 Day Acuvue Dailies PureVision 2 PureVision 2 for Astigmatism PureVision 2 for Multifocal BioTrue Dailies Biofinity Other
        How many hours a day do you wear your contacts?  Less than 8 hours 9 to 12 hours More than 12 hours Sleep in contacts Other

        How often do you dispose your contacts?  1 week 2 Weeks every month every 3 months every year Other    Do you Sleep or nap in contacts?  Never Occasionally Always Other

        What solutions do you use to clean and disinfect your contacts?  Do not know Generic Optifree Clearcare Other    Do you wear UV coated sunglasses?  yes no Other

        E. GENERAL HEALTH HISTORY

        Last general health exam:  Never 1 Year ago 6 months ago 3 months ago Other         Doctor's name? 
        Doctor's Address:   Doctor's Phone: 

        Please Check all health conditions that apply to you:                 Family Members with health conditions (blood relatives only)

Seasonal Allergies	Headaches	My  Mother Father Grandfather Grandmother Brothers Sisters Other     Has  Seasonal Allergies Arthritis Asthma Cancer Diabetes Headaches Heart Disease HIV Hypertension Lung Disease Seizures Vascular Disease Other
Arthritis	Heart Disease	My  Mother Father Grandfather Grandmother Brothers Sisters Other     Has  Seasonal Allergies Arthritis Asthma Cancer Diabetes Headaches Heart Disease HIV Hypertension Lung Disease Seizures Vascular Disease Other
Asthma	HIV	My  Mother Father Grandfather Grandmother Brothers Sisters Other     Has  Seasonal Allergies Arthritis Asthma Cancer Diabetes Headaches Heart Disease HIV Hypertension Lung Disease Seizures Vascular Disease Other
Cancer	Hypertension
Diabetes	Lung Disease
Seizures	Vascular disease

        Have you had any Medical Surgeries:

        F. MEDICATIONS

        I take  None Other   For  Do not know Other       Please list any additional Medications: 

        I take  None Other   For  Do not know Other       Please list any Medication Allergies: 

        I take  None Other   For  Do not know Other

        G. LIFESTYLE QUESTIONS

        These questions are intended to assist us in better meeting your everyday VISUAL needs.

        How many hours do you spend on a computer?  None Less than an Hour More than an hour Other   Reading / Deskwork?  None Less than an Hour More than an hour Other

                                                                             Outdoors:  None Less than an Hour More than an hour Other         Nightime Driving?  None Less than an Hour More than an hour Other

Which Sports do you participate in?
None                      Ice Skating              Football             Hunting
Basketball             Martial Arts             Swimming         Water Skiing
Baseball/Softball  Snow Skiing          Golf
Fishing                    Soccer                    Tennis

        I want the style of my frames to be:  Don't know Trendy Conservative Dressy Sporty Other   I want my frames to be made of:  Metal Plastic Rimless Titanium Carbon Fiber Other
        I want my lenses to be: 
        Please select all your preferences from the following:
         Reflection/Glare Free         Transitions   Thin and Lite Weight
         UV Coated for Protection   Polarized Sunglasses to Reduce Glare   Aspheric Design to Reduce Coke Bottle Effect

        Has there been a time when you wish you were NOT wearing eyeglasses? 
        If yes, would you like to know if you are a candidate for contact lenses:  contact lenses Lasik both Other
        Are you interested in colored contacts:  Yes No Other
Please click on the 'Patient Signature' tab and complete it

Patient Signatures

        HIPAA Privacy Policy, Preferred Method of Contact, Financial Agreement and Consent to Treatment:
        Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

         View HIPAA Patient Privacy Policy Form
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        Enter your cell#, email address, Home Phone, or Home Address:  

        * I have read, understood, received and accept Eyeland Vision's Privacy Policy regarding why you may contact me and how my health information is used and disclosed.
        **Please enter First and Last Name: 

        View Financial Agreement and Consent to Treatment Form
        *I have read, understood, received and accept Eyeland Vision's Financial Agreement and Consent to Treatment.
        **Please enter First and Last Name: 

        ** By entering my First and Last name, I understand, agree and accept that I am constituting a legally binding electronic signature which I
        accept has the same validity and meaning as my handwritten signature.

Thank you for trusting Eyeland Vision with the care of your eyes!Congratulations! Now you can SUBMIT your data on the last tab.

Submit Data

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Please bring your driver's license, all your insurance cards, and any glasses you wear to your appointment.