Empire Optometry

Prefix

Preferred Name

Name*

First Middle Last

Date of Birth*

Gender

Male
Female

Marital Status

Address

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

Social Security Number

Home Phone

Day Phone

Cell Phone

Email

Person Responsible for Account

Emergency Contact

First Last

Emergency Contact Phone

How were you referred to our office?

Who referred you?

Primary Insurance Information

Primary Insurance Company Name

ID #

Group #

Insurance Company Address

Street Address City State / Province / Region ZIP / Postal Code

Is the patient the subscriber?

No
Yes

Patient Relationship to Subscriber

Name of Subscriber

First Last

Subscriber Gender

Male
Female

Subscriber Date of Birth

Is there a secondary insurance?

Yes
No

Insurance Company

ID #

Group #

Address of Insurance Company

Street Address City State / Province / Region ZIP / Postal Code

Patient Relationship to Subscriber

Name of Subscriber

First Last

Subscriber Gender

Male
Female

Subscriber Date of Birth

Please Read

When you sign this consent document, you signify that you agree that we can and will use and disclose your health information to treat you, to obtain payment for our services, and to perform health care operations. You agree to pay for any provided services not covered by your insurance. You can revoke this consent in writing at any time, unless we have already treated you, sought payment for our services, or performed health care operations in reliance upon our ability to use, or disclose your health information in accordance with this consent. You have the right to ask us to restrict the use, or disclosures made for purposes of treatment, payment, or health care operations, but as described in our Notice of Privacy Practices, we are not obliged to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.

I have read this, consent to and understand it. I consent to the use and disclosure of my health information for the purposes of treatment, payment, and health care operations. I acknowledge that I have received and/or read the Notice of Privacy Practices from Empire Optometry. Signed:*

Today's Date*

Patient History and Information

Race

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Native American
Caucasian
Not Disclosed
Other

Please specify:

Preferred Language

Primary Care Physician

PCP Clinic Name / Address if known

Phone

Referring Physician

Clinic Name / Address if known

Phone

What is the main reason for today's exam?

When was your last eye exam?

When was your last physical exam?

List past illnesses or injuries

List past surgeries

List current medications (including eyedrops)

List your allergies (medication and other)

Eye History

General Health Condition

Do you have a family history of the following?

Social History

Current Occupation

Since

Employer

Do you use a computer?

Yes
No

How many hours/day?

Distance from screen?

Do you drive?

Yes
No

Average miles/day?

Do you have visual difficulty while driving?

Yes
No

Do you have glare problems?

Yes
No

Do you have difficulty with night vision?

Yes
No

Do you take any nutritional supplements? (Vitamins, etc.)

Yes
No

Do you engage in regular exercise?

Yes
No

Do you drink alcohol?

Yes
No

How many drinks, on average?

Do you smoke?

Yes
No
I use chewing tobacco.

How much do you smoke/chew?

Do you use any illegal drugs?

Yes
No

What are your hobbies/interests?

Lens History

Do you wear glasses?

Yes
No

How long have you worn glasses?

When do you wear your glasses?

Full time
Part time
Close
Distance

What type(s) of glasses do you have?

Single Vision
Bifocals
Trifocals
Backup
Safety
Sports
Progressive

Have you had trouble in the past with glasses? Please describe.

Do you wear sunglasses?

Yes
No

Is the prescription current?

Yes
No

Special eyewear needs?

Computer (special prescriptions, special anti-glare tints or coatings)
Occupational (mechanics, plumbers, pilots)
Safety Glasses (gardening, woodworking, welding)
Sports/Hobbies (raquet sports, motorcycle)

Do you wear contact lenses?

Yes
No

How long have you worn contacts?

Have you ever tried wearing contacts?

Yes
No

Are you interested in trying contact lenses?

Yes
No

Type and Brand of Contact Lenses

How many hours/day do you wear your contacts?

How many days/week do you wear your contacts?

What contact solution do you use?

Any issues with comfort or vision with either contact lens?