4985 form

1523 North Aurora Road Ste 115
Naperville, IL 60563
Phone: (630) 579-6400
fax: (630) 579-6444

Name*
First Last
Date
MM slash DD slash YYYY
Email address
Birthdate:*
Reason for Today's Visit:
Check any of the following conditions that a doctor has diagnosed you with:
- Age-related macular denegration
- Eye infection, inflammation, or allergy
- Retina defects or degenerations
- Glaucoma
- Diabetes
- Floaters
- Flashes
- Cataract
- Diabetic Retinopathy
- Dry Eye
- Iritis or Uveitis
Other:
Details of condition:
Check any of the following you plan to purchase:
- New Glasses
- Prescription Sunglasses
- Non-Prescription Sunglasses
- Computer Glasses
- Reading Glasses
- Sports Glasses
- New supply of Contact Lenses
Vision Performance:
Do you have poor reading skills or low performance?
- Yes
- No
Do you have inconsistent sports vision performance?
- Yes
- No
Do you have slowness when shifting focus?
- Yes
- No
Do you have difficulty with 3-D images, movies, or TV?
- Yes
- No
Computer Demands:
Computer use for an extended period
- Yes
- No
Unusual ergonomic demands
- Yes
- No
Must view paperwork and computer simultaneously
- Yes
- No
Use of laptop
- Yes
- No
Use of multiple desktop monitor's
- Yes
- No
Hours of computer use, per day:
Outdoor Demands:
Extended night driving
- Yes
- No
Outdoors in direct UV exposure
- Yes
- No
Read in outdoor settings
- Yes
- No
Irritated contact lenses when outdoors
- Yes
- No
Eye Concerns
Select Yes or No. If selecting yes, you will be prompted to select which eye(s) you are experiencing concerns in.
Redness
- Yes
- No
Please check left or right, check both if applicable.
- Left
- Right
Burning
- Yes
- No
Please check left or right, check both if applicable.
- Left
- Right
Itching
- Yes
- No
Please check left or right, check both if applicable.
- Left
- Right
Excess Tearing
- Yes
- No
Please check left or right, check both if applicable.
- Left
- Right
Mucus Discharge
- Yes
- No
Please check left or right, check both if applicable.
- Left
- Right
Vision Concerns:
Select Yes or No. If selecting yes, you will be prompted to select which areas you are experiencing concerns in.
Blurred Vision
- Yes
- No
Please check left or right, check both if applicable.
- Left
- Right
Eyestrain
- Yes
- No
Please check left or right, check both if applicable.
- Left
- Right
Eye Pain or Soreness
- Yes
- No
Please check left or right, check both if applicable.
- Left
- Right
Light Sensitivity
- Yes
- No
Please check left or right, check both if applicable.
- Left
- Right
Headaches
- Yes
- No
Please select which areas
- Temple
- Eye area
- Back of head
- Forehead
Poor night vision
- Yes
- No
Please check left or right, check both if applicable.
- Left
- Right
Bothersome Night Glare
- Yes
- No
Please check left or right, check both if applicable.
- Left
- Right
Double Vision
- Yes
- No
Please check left or right, check both if applicable.
- Left
- Right
Total Loss of Vision
- Yes
- No
Please check left or right, check both if applicable.
- Left
- Right
Other:
Are you interested in any of the following:
- New contact lens fitting
- New technology or more comfortable contact lenses
- One-day use contact lenses
- Contact lenses of a different replacement period
- Contact lenses for safe overnight wear
- Corneal-reshaping contact lenses
- Vision therapy
- Laser vision correction
Please check all that apply.
Review of Systems
Do you currently have, or have you ever had any problems in the following areas:
System
Developmental Disabilities
- Yes
- No
Cancer
- Yes
- No
Type:
Fatigue Syndrome
- Yes
- No
Other:
Ear, Nose, Mouth, Throat
Hearing Loss
- Yes
- No
Sinusitis
- Yes
- No
Dry Throat/Mouth
- Yes
- No
Laryngitis
- Yes
- No
Other:
Neurological
Multiple Sclerosis
- Yes
- No
Epilepsy
- Yes
- No
Cerebral Palsy
- Yes
- No
Stroke/CVA
- Yes
- No
Migraine
- Yes
- No
Other:
Psychiatric
Depression
- Yes
- No
Attention Deficit
- Yes
- No
Anxiety Disorder
- Yes
- No
Bipolar Disorder
- Yes
- No
Other:
Cardiovascular
High Blood Pressure
- Yes
- No
Stroke/CVA
- Yes
- No
Heart Disease
- Yes
- No
Vascular Disease
- Yes
- No
Congestive Heart Failure
- Yes
- No
Other:
Respiratory
Cigarette Smoker
- Yes
- No
Asthma
- Yes
- No
Bronchitis
- Yes
- No
Emphysema
- Yes
- No
Chronic Obstruction
- Yes
- No
Sleep Apnea
- Yes
- No
Gastrointestinal
Crohn's
- Yes
- No
Colitis
- Yes
- No
Ulcer
- Yes
- No
Acid Reflux
- Yes
- No
Celiac Disease
- Yes
- No
Other:
Genitourinary
Kidney Disease
- Yes
- No
Prostate Disease/Cancer
- Yes
- No
STD/Herpetic/Chlamydia/Herpes
- Yes
- No
Benign Prostate Hypertrophy
- Yes
- No
Pregnant (Currently)
- Yes
- No
Nursing (Currently)
- Yes
- No
Musculoskeletal
Arthritis
- Yes
- No
Osteoarthritis
- Yes
- No
Fibromyalgia
- Yes
- No
Muscular Dystrophy
- Yes
- No
Ankylosing Spondylitis
- Yes
- No
Osteoporosis
- Yes
- No
Gout
- Yes
- No
Skin (Integumentary) list:
Endocrine
Diabetes
- Yes
- No
Thyroid/Other Gland
- Yes
- No
Lymphatic/Hematologic
Anemia
- Yes
- No
Bleeding Problems
- Yes
- No
Liver
- Yes
- No
Other:
Allergic/Immune
Drug Allergies
- Yes
- No
Environmental Allergies
- Yes
- No
Rheumatoid Arthritis
- Yes
- No
Lupus
- Yes
- No
Sjogren's Syndrome
- Yes
- No
Latex Allergy
- Yes
- No
Please list medications you are taking and dosages (including oral contraceptive, aspirin, OTC medications and home remedies)
Please explain any allergies to specific medications or environmental allergies:
Social History
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
Do you drink alcohol?
- Yes
- No
If yes, type/amount/how long?
Do you use tobacco products?
- Yes
- No
If yes, type/amount/how long?
If not, are you a former smoker?
- Yes
- No
What hobbies, sports, or activities do you participate in?
Family Medical History
Please specify Father, Mother, Brother, Sister, Son, or Daughter.
Cancer
- Yes
- No
Relation:
Diabetes Type 1
- Yes
- No
Relation:
Diabetes Type 2
- Yes
- No
Relation:
High Blood Pressure
- Yes
- No
Relation:
Hyperthyroidism
- Yes
- No
Relation:
Hypothyroidism
- Yes
- No
Relation:
Other:
Family Ocular History
Please specify Father, Mother, Sister, Son, or Daughter.
Cataract
- Yes
- No
Relation:
Macular Degeneration
- Yes
- No
Relation:
Glaucoma
- Yes
- No
Relation:
Other:
SIGNATURE OF PATIENT*
(Parent signature if patient is a minor)
FOR MORE INFORMATION

If you would like more information about our privacy practices, call or visit the office at the address or phone number shown at the beginning of this Notice.

ACKNOWLEDGMENT OF RECEIPT

I acknowledge that I received a copy of Timothy J. Morrison, O.D.’s Notice of Privacy Policies
Patient Signature (if patient is a minor, signature of parent/guardian)
Date
MM slash DD slash YYYY
PAYMENT POLICY
The Professional Service fees (including Exam copays and contact lens evaluation fees) are due at the time of services. All contact lenses must be paid in full before ordering. All glasses must be paid in full before dispensing. If you have insurance coverage for these services or materials, Morrison Eyecare will submit claims on your behalf.

However, we are not liable for collecting your claim. After 30 days, we will expect payment in full if your insurance company has not reimbursed Dr. Morrison.
I HEARBY AUTHORIZE MY INSURANCE CARRIER TO MAKE PAYMENTS DIRECTLY TO MORRISON EYECARE FOR ANY AND ALL SERVICES RENDERED TO ME BY MORRISON EYECARE. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT COVERED BY INSURANCE.
- Yes
- No
I also release any information regarding my treatment or condition in order to obtain payment for professional services.
- Yes
- No
I acknowledge any patient not providing 24 hour notice of cancellation will be charged a $25 cancellation fee
- Agree
I HAVE READ AND AGREE TO THE PAYMENT POLICY STATED ABOVE.
Patient Signature
Date
MM slash DD slash YYYY
OptoMap SCREENING FEE AGREEMENT

An OptoMap Wellness Scan is Dr. Morrison’s preferred method of evaluating your retina, which checks the health of your eye and allows Dr. Morrison to detect signs of disease including, but not limited to glaucoma, macular degeneration, diabetes, tumors, retinal detachments, and hypertension.
The additional cost of the OptoMap Wellness Scan is only $45, and through this service you can often avoid the inconvenience of a dilated retinal evaluation. Early detection of both ocular and systemic disease is essential to your overall health.
I HAVE READ AND*
- AGREE TO THE OPTOMAP SCREENING FEE AGREEMENT AND ACCEPT THE $45 CHARGE FOR THE OPTOMAP ULTRA-WIDE LASER RETINAL SCANNER
- DISAGREE
Patient Signature
Date
MM slash DD slash YYYY

Vision Performance:

Computer Demands:

Outdoor Demands:

Eye Concerns

Vision Concerns:

Review of Systems

Social History

Family Medical History

Family Ocular History