Online Patient Form

Demographics

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev. 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	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Polygamous Widowed	Employer / School Name
Misc/Guardian

Referred By:

Referring Doctor:

Are any family members seen by our office?:

Is the Billing Address Different?

Billing Information

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

Copy Address From Above
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 History

Please choose from the menu options or select "OTHER" to type in multiple items or your own text. Thank you!

Interested In Contact Lenses?

Yes No

Ever Worn Contact Lenses?

Currently Prior Never

If yes, type of contacts worn in past:

Disposables Extended Wear Gas Permeables Gas Perm Bifocals Gas Perm Bitorics Gas Perm FS Toric Monovision - Soft Monovision - Disposables Monovision - Gas Perm No CL Hx Soft Daily Wear Soft Torics Other

Do you have backup glasses?:

Yes No Other

Primary Vision Correction:

Bifocals Contacts Contacts - Mono None Progressives Single Vision Trifocals Other

Do you want sunglasses?:	Yes No	Do you want computer glasses?:	Yes No
Do you have problems with glare?:	Yes No	Interested in Laser Vision Correction?:	Yes No

Do you currently have or have a history of the following conditions/symptoms?:

None Itching Burning, Stinging Amblyopia Eye Injuries Eye Surgery Flashes Of Light Floaters Strabismus Cataracts Glaucoma Retinal Disorders Macular Degeneration Other

Do you take any eye medications?:

None Acular Artificial Tears Betoptic-S .25% Betoptic .5% Betagan Erythromycin FML FML Forte Gentamicin Neosporin None Ocupress Pilo Gel Propine Polytrim Pred Mild Pred Forte Patanol Timoptic .25% Timoptic .5% Tobradex Voltaren Xalatan Other

Last Eye Doctor:

Dr. Ellen Crothers Dr. Michaela Novak Dr. Natascha Mellis Other Never Been Don't Remember

Primary Care Physician:

Bribiesca M.D. Blancarte M.D. Cartall M.D. Dawson M.D. Dewitt M.D. Franklin M.D. Grave M.D. Greer M.D. Gamble M.D. Hanley M.D. Hanna M.D. Hudson M.D. Kapada M.D. Ligon M.D. Legget M.D. Mallaske M.D. Marchand M.D. Meyerson M.D. Moran M.D. Pampe M.D. Reid M.D. Rasor M.D. Robitaille M.D. Roane M.D. Sneed M.D. Sherman M.D. Sonstein M.D. Teel M.D. Vail M.D. Weidman M.D. Wiggins M.D. Other Don't Have One Don't Remember

Do you take any other medications?:	See ARRA None Allegra D Birth Control Claritin Chlor-Trimeton Inderal Librax Muscle Relax Minipress Premarin Pamelor Plaquenil Reglan Relafen Sinequan SLO-BID Seldane Synthroid Seldane-D Thyroxine Verapamil Zocor Zoloft Zantac Other
Do you have any allergies?:	NKDA None Erythromycin Iodine Pollen PCN Sulfa Codeine Tetanus Other

Please describe any history of conditions such as asthma, diabetes, thyroid disease, etc.:

Family Med History:	Arthritis Cancer Diabetes I Diabetes II Hypertension Hypercholesterolemia Heart Disease Other
Family Eye History:	None Amblyopia Cataracts Glaucoma Macular Degeneration Retinal Detachment Weak Eye Lazy Eye Other

Speed Testing

Report The FREQUENCY Of The Below Symptoms as Never, Sometimes, Often, Or Contant Using The Number System Below:

Race:

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

Ethnicity:

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

Preferred Language:

English French German Spanish 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

Symptoms	0	1	2	3
Dryness, Grittiness Or Scratchiness
Soreness Or Irritation
Burning Or Watering
Eye Fatigue

0 = Never , 1 = Sometimes, 2 = Often, 3 = Constant

Report The SEVERITY Of Your Symptoms By Using The Rating List Below:

Symptoms	0	1	2	3	4
Dryness, Grittiness Or Scratchiness
Soreness Or Irritation
Burning Or Watering
Eye Fatigue

0 = No Problems
1 = Tolerable - Not Perfect But Not Uncomfortable
2 = Uncomfortable - Irritating But Does Not Interfere With My Day
3 = Bothersome - Irritating And Interferes With My Day
4 = Intolerable - Unable To Perform My Daily Tasks

How Long Have You Been Treated For Dry Eye Disease?

Less Than One Year 1 - 2 Years More Than 2 Years No H/O TXT

Do You Experience Any Of The Following Symptoms?

Dry Mouth	Muscle Weakness Or Numbness Of Your Arms And Legs
Fatigue	Inability To Concentrate
Body Aches	GI Distress
None Apply

Have You Or A Family Member Ever Been Diagnosed With An Autoimmune Disease Such As Lupus, Rheumatoid Arthritis, Sjogren's Or Other Associated Autoimmune Disease?
No Myself Family Member
Do You Use Drops And / Or Ointment Yes No How Often?
What Drops Do You Use?

Indicate Time Spent:

On A Computer At Work: Hours Per Day
On A Computer At Home: Hours Per Day
On A Handheld Computer (e.g. Smartphone, Tablet): Hours Per Day

Are You Experiencing Any Of The Following Symptoms While At Your Computer Monitor Or Using Handheld Devices?:

Blurred Distance Vision	Trouble Changing Focus From Near To Far
Blurred Near Vision	Glare (Light) Sensitivity
Head Aches	Back Pain
Double Vision	Neck And Shoulder Pain
Sore / Tired Eyes (Eye Strain)	Dry Or Watery Eyes
Burning, Irritation, Itch	None Apply

Review of Systems

General:	None Fatigue Fever Loss of Appetite Weight Gain Weight Loss Developmental Disorders Other	Ears/Nose/Throat:	None dry mouth cough ear ache hard of hearing stuffy nose Other
Cardiovascular:	None High BP racing pulse Other	Respiratory:	None congestion short of breath wheezing Other
Genitourinary:	None frequent urination impotence painful urination yellow jaundice Other	Musculoskeletal:	None arthritis cramps joint pain stiffness swelling Other
Skin:	None growths pimples, warts rash Other	Neurological:	None headache numbness, paralysis seizures Other
Psychiatric:	None anxiety depression insomnia Other	Endocrine:	None diabetes hypothyroid Other
Blood/Lymph:	None anemia bleeding cholestrolemia Other	Allergy/Immune:	None hives itching lupus redness sneezing swelling Other

Submit Data / Signatures

For Patients Filing Insurance Claims

As a service to our patients, we do our best to verify medical and vision insurance benefits. However, we are not responsible for incorrect benefit information given to us by your insurance company regarding coverage, allowances, co-pays, or other information needed to file an insurance claim.

I, , understand that I am responsible for any amount not covered or paid by my insurance for services and/or materials provided by Arbor Eye Center, P.A. I accept that full payment is expected within 30 days of such notice from the date the bill was mailed.

Signature: Date:

HIPAA

Acknowledgment of Receipt

I acknowledge that I received a copy of Arbor Eye Center, P.A.'s Notice of Privacy Practices.

Signature: Date:

Dilation

Pupil dilation is part of the comprehensive eye exam, and it is included in the cost of the exam. It allows a more thorough evaluation of the retina so that the doctor may check for undiagnosed conditions or diseases. Without a dilated exam, many vision-threatening conditions may go undetected because patients may not experience any symptoms. Dilation is particularly important for people with diabetes.

Please be advised that the side affects of dilation will include light sensitivity and blurry near vision for three to six hours

Optomap

The optomap digital retinal imagining captures a 200 degree view and more than 80% of your retina in one image. The wide view enhances your doctors ability to detect even the earliest sign of disease. If you choose to have optomap imaging in lieu of dilation drops today, we will have an image to keep on record that is useful for future comprehensive exams and maintaining eye health. The optomap does not have any side effects and allows the doctor to review the image with you at the time of exam. If you choose to do the optomap and the doctor does detect any sign of disease, the doctor will advise you on next steps which may involve dilation.

The optomap is not covered by most insurance plans and is an additional charge of $39. We will inform you if the optomap charge is covered by your insurance plan at the time of visit

After reviewing my options with the presented material and given the opportunity to ask questions, I have made the following decision:

I would like a comprehensive exam including the dilation drops

*please note if you have been diagnosed with diabetes, have a history of seizures, or have had retinal surgery the doctors prefer to perform a dilated fundus exam.

I would like a comprehensive exam including the optomap imaging

I do NOT consent to having a dilated examination or optomap imaging performed. I understand the importance of this test and that Arbor Eye Center, P.A. is not liable for failure to test or diagnose any eye condition(s) due to lack of diagnostic information that would have been obtained in performing this test.

I do NOT consent to a dilated eye exam because I see a retinal specialist who dilates my eyes every year.

Date of last dilated fundus exam:

I do NOT consent to a dilated eye exam because I am pregnant or nursing

*please note the optomap is an excellent and safe alternative to dilation.

I do NOT consent to a dilated eye exam due to other reasons.

Please list:

Print Name: Date

Signature: