4985 form

Name*

First Last

Date

Email address

Birthdate:*

Reason for Today's Visit:

Check any of the following conditions that a doctor has diagnosed you with:

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

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

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