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Columbia Point Vision Clinic
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2017-07-06T01:14:21+00:00
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
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Ghana
Gibraltar
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Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
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Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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)
Allergies
Arthritis
Blood/Lymph
Bronchitis
Cancer
Cholesterol
Diabetes
Digestive
Ear/Nose/Throat
Eczema/Rashes
Fatigue
Fevers
Genitourinary
Hep C/HIV/AIDS
High Blood Pressure
Integumentary (skin)
Kidney
Muscle/Bone
Neurological
Psychological
Respiratory
Sinus
Throat Infections
Thyroid
Unusual weight losses/gains
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)
Blindness
Cataracts
Glaucoma
Macular Degeneration
Retinal Problems
Corneal Problems
Lazy Eye/Eye Turn
Diabetes
HTN
Cancer
Thyroid Disease
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:
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