Columbia Point Vision Clinic

Patient Information

Today's Date*

Name*

First Middle Last

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Work Phone

Cell Phone

Email

How do you prefer to be contacted?

Home #
Work #
Cell #
Text
Email

Which methods of contact selected above should we try first?

Patients SSN

Employer (or school)

Occupation (or grade)

Spouse (or parent's name)

Spouse's work (or parent's work)

Sex

Male
Female

What is the major purpose of this visit?

Are there any problems with your current contact lenses or glasses?

NEW PATIENTS ONLY: Who may we thank for referring you to our office?

Name of friend or relative

NEW PATIENTS ONLY: If not referred, how did you choose our office?

Another Doctor
Insurance List
Saw roadside Billboard/Building
Newspaper/Radio/TV
Yellow Pages
Website

Insurance Information

Please note that insurance does NOT cover the Contact Lens Evaluation

Vision Insurance*

Subscriber Name

First Last

Subscriber SSN

Subscriber Birth Date

Primary Medical Insurance

Subscriber Name

First Last

Subscriber SSN

Do you participate in a flex spending account?*

Yes
No

Subscriber Birth Date

How will you settle your account?*

Cash
Check
Credit Card

Lifestyle Questions

Do you... (Check if yes)

Work at a computer?
Think you might benefit from thinner, lighter lenses?
Spend time outdoors?
Have prescription sunwear?
Prefer not to wear glasses at times?
Have more than 1 pair of current prescription eyewear?
Have children?
Have family members in need of eye care?

Have you ever experienced, been diagnosed or treated for any of the following?

Blurry vision
Cataracts
Crossed eye/eye turn
Eye infections
Flashes of light
Floaters
Glaucoma
Headaches

(Check if yes)

Patient Medical History

Name of Family Physician

Town

Date of Last Physical Checkup

Current Medications (RX or Over the Counter)

Please list name of medications including eye drops, vitamins, and birth control pills.

Allergies to medications?*

Yes
No

If so, what medications?

Have you had any surgeries?*

Yes
No

Do you use any of the following substances?

Cigarettes/Tobacco
Alcohol
Other

Have you ever been diagnosed or treated for the following health problems?

(Check if Yes)

Patient Eye History

Date of Last Eye Exam

By whom?

Contact Lens Information

Do you currently wear contact lenses?*

Yes
No

If yes, what kind?

Which solutions do you use?

Are you satisfied with the comfort?

Yes
No

Are you interested in a "test drive" of the latest contact lens designs?

Yes
No

If no, have you ever tried contact lenses?

Yes
No

If no, are you interested in contact lenses?

Yes
No

If no, are you interested in colored lenses?

Yes
No

Family Medical History

Is there a family history of any of the following?

(Check if yes)

I acknowledge that I have read, or had the opportunity to read if I so chose, and understood the Notice of Privacy Practices (NPP) and agree to its terms.*

Today's Date:

Signature