Empire Optometry

Prefix
Preferred Name
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
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
MM slash DD slash YYYY
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
MM slash DD slash YYYY
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*
MM slash DD slash YYYY
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?
MM slash DD slash YYYY
When was your last physical exam?
MM slash DD slash YYYY
List past illnesses or injuries
List past surgeries
List current medications (including eyedrops)
List your allergies (medication and other)
Eye History
- Glaucoma
- Cateract
- Macular Degeneration
- Retinal Detachment
- Color Blindness
- Headaches
- Glare/Light Sensitivity
- Tired Eyes
- Amblyopia (Lazy Eye)
- Burning
- Dryness
- Excess Tearing/Watering
- Eye Pain or Soreness
- Foreign Body Sensation
- Infection of Eye or Lid
- Itching
- Mucous Discharge
- Drooping Eyelid
- Redness
- Sandy or Gritty Feeling
- Strabismus (Crossed Eyes)
- Blurred Vision Distance
- Blurred Vision Near
- Distorted Vision (halos)
- Double Vision
- Floaters or Spots
- Fluctuating Vision
- Loss of Vision
- Loss of Side Vision
General Health Condition
- Fever
- Weight Loss
- Other Symptoms
- Ear, Nose, Throat
- Cardiovascular (high blood pressure, etc.)
- Respiratory (Asthma
- Gastrointestinal
- Kidney
- Muscles, Bones, Joints
- Skin
- Neurological (Multiple Sclerosis)
- Anxiety or Depression
- Thyroid, Diabetes
- Blood/Lymph
- Allergic
- Pregnant
- Nursing
Do you have a family history of the following?
- Amblyopia (Lazy Eye)
- Blindness
- Cataracts
- Color Blindness
- Glaucoma
- Macular Degenertion
- Retinal Detachment
- Strabismus (Eye Turn)
- Arthritis
- Cancer
- Diabetes
- Heart Disease
- High Blood Pressure
- Kidney Disease
- Lupus
- Stroke
- Thyroid Disease
- Other
Social History
Current Occupation
Since
MM slash DD slash YYYY
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?

Empire Optometry

Primary Insurance Information

Please Read

Patient History and Information

Social History

Lens History