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Eldorado Vision & Optical
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2017-07-06T01:14:26+00:00
Eldorado Vision & Optical
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Primary Medical Insurance
Insurance Type
PPO
HMO
Insurance Company Name
ID #
Group #
Policy Holder Name
First
Last
Insurance Telephone #
Secondary Insurance to Medicare
Insurance Company Name
ID #
Group #
Policy Holder Name
First
Last
Insurance Telephone #
Vision Insurance
Insurance Company Name
ID #
Policy Holder Name
First
Last
Insurance Telephone #
Referral Information
Individual
First
Last
Relationship to you
Did you hear about us from any of the following?
Internet
Facebook
Insurance
Website
Other
If other:
Have you had any changes in last 6-9 months to your:
Distance Vision
Near Vision
Computer Vision
Daily hours on digital devices
Have you experienced any of the following eye problems in the last 6 months?
Itching
Burning
Red
Gritty
Watery
Dry
History of eye diseases, eye injuries, eye surgeries:
Check if you have had any of the following
Glaucoma
Macular Degeneration
Cataracts
Retinal Problems
Droopy Eyelids
Cataract Surgery
Lasik Surgery
Other
If other:
Current Eye Medications
Eyedrops, prescriptions, over-the-counter eye medications, etc.
Date of Last Eye Exam
MM slash DD slash YYYY
Doctor
Primary Vision Correction
Glasses
Contact Lenses
Readers
None
Contact Lens Type
Soft Lens Disposable
Rigid Gas Permeable
None
Days/Week you wear contact lenses
Hours per day you wear contact lenses
Comfortable wearing hours per day
Race
American Indian or Alaska Native
Black or African American
White
Native Hawaiian or other Pacific Islander
Other
Decline
Ethnicity
Hispanic or Latino
Non Hispanic or Latine
Unknown
Decline
Ever Smoked
Yes
No
Current Smoker
How many years?
Do you consume Alcohol?
Yes
No
How often?
Occasional
Social
What kind?
Beer
Wine
Liquor
# of years
Recreational Drugs
Yes
No
Height
Weight
Current Flu Shot
Yes
No
Current Tetanus Shot
Yes
No
Occupation
Hobbies
Your Health Information
Primary Care Physician
Date of last visit to PCP
MM slash DD slash YYYY
Reason for visit
Annual Exam
Recent problem
Special Testing
List all Medications
Pregnant or nursing?
Yes
No
Drug Allergies
Injuries, Surgeries, Hospitalizations in last 2 years
Issues in any of the following areas?
Ear, Nose, Throat (ENT)
Cardiovascular (Heart)
Respiratory
Genital-Kidney-Bladder
Muscle-Bone-Joint
Skin
Neurological
Psychiatric
Endocrine
Blood-Lymphatic
Allergies - Seasonal
Gastrointestinal
Family Health Information
Siblings, Parents, Grandparents
Cataracts
Glaucoma
Macular Degneration
Retinal Detachment
Cross Eye / Blind Eye
Cancer
Cardiovascular (Heart)
High Blood Pressure
High Chloestrol
Stroke
Diabetes
Throid
Lupus
Arthritis
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