Manteca and Midtown Optometry

Patient Information
Today's Date
MM slash DD slash YYYY
Reason for Today's Visit
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Patient's SSN
Date of Birth
MM slash DD slash YYYY
Age
Gender
- Male
- Female
- Other
Employer (or School)
Occupation
Spouse (or Parent's Name)
Email Address
Date of Last Exam
MM slash DD slash YYYY
By Whom?
Who may we thank for referring you to our office?
Name of friend or relative
If not referred, how did you choose our office?
- Another Dr.
- Saw Sign/Building
- Yellow Pages
- Insurance List
- Newspaper/Radio/TV
- Web Page
Other (Please describe):
Insurance Information
Please note that insurance may NOT cover the Contact Lens Evaluation.
Vision Insurance
Subscriber Name
Subscriber SSN
Subscriber Birth Date
MM slash DD slash YYYY
Primary Medical Insurance
Subscriber Name
Subscriber SSN
Subscriber Birth Date
MM slash DD slash YYYY
Do you participate in Flex spending account?
- No
- Yes
How will you settle your account today?
- Cash
- Check
- Credit Card
Patient Medical History
Name of Family Physican
Town/City
Date of Last Physical Check-up
MM slash DD slash YYYY
CURRENT MEDICATIONS
List name of medications including eye drops, vitamins, & birth control pills
Allergies to Medications?
- No
- Yes
If YES, what medications?
Have you had any surgeries?
- No
- Yes
If YES, what surgeries?
Do you use cigarettes/tobacco, alcohol, or other substances?
- No
- Yes
Have you ever been diagnosed or treated for the following health problems?
- Allergies
- Arthritis
- Blood/Lymph
- Bronchitis
- Cancer
- Cholesterol
- Digestive
- Ears/Nose/Throat
- Endocrine
- Eczema/Rashes
- Fatigue
- Fevers
- Genitourinary
- High Blood Pressure
- Integumentary (Skin)
- Kidney
- Muscle/Bone
- Neurological
- Pyschological
- Respiratory
- Sinus
- Throat Infections
- Thryoid
- Unusual weight losses/gains
Family Medical/Eye History
Is there a family medical history of any of the followin
- Blindness
- Cataracts
- Corneal Problems
- Diabetes
- Glaucoma
- Heart Disease
- Lazy Eye
- Macular Degeneration
- Retinal Problems
Eye Conditions
Have you ever been diagnosed with any of the following conditions? Conditions previously noted by your doctor will be...
- Cataract
- Age-related Macular Degen
- Glaucoma
- Diabetes
- Diabetic Retinopathy
- Dry Eye
- Eye Infection/Inflammation/Allergy
- Floaters/Flashes of Light
- Iritis/Uveitis
- Retinal Defects/Degenerations
Other (Please describe):
Eye Concerns
Are you having any of the following eye concerns?
- Redness
- Burning
- Itching
- Tearing
- Discharge
Other (Please describe):
Vision Concerns
Are you having any of the following vision concerns?
- Blurred Vision
- Eyestrain
- Eye Pain
- Severe Sensitivity to Lights
- Headache
- Poor Night Vision
- Bothersome Night Glare
- Double Vision
- Total Loss of Vision
Other (Please describe):
Vision Correction
What corrective lenses are you main using for far/distance vision activities
Describe the quality of your far/distance vision activities:
What corrective lenses are you mainly using for near/reading vision activities?
Describe the quality of your near/reading vision activities:
What corrective lenses are you mainly using for computer vision activities?
Describe the quality of your computer vision activities:
Computer Demands
Do you have any of the following computer demands on your vision?
- Computer use for extended periods
- Unusual ergonomics demands
- Must simultaneously view paperwork and computer
- Use of laptop
- Use of multiple desktop monitors
Other (Please Describe):
Performance & Outdoor
Do you have any of these vision performance problems?
- Poor reading skills or low reading
- Inconsistent sports vision
- Slowness when shifting focus
- Difficulty with 3-D images, movies, or TV
Other (Please Describe):
Outdoor Demands
Describe any special demands
- Extended night driving
- Outdoors in direct UV exposure
- Read in outdoor settings
- Irritated contact lenses when outdoors
Other (Please Describe):
Eyeglass Desires
Do you have any of the following desires for your glasses?
- Replace uncomfortable, broken, or lost eyeglasses
- Need extra eyeglasses for special activities
- Interest in specific fashion or brands
- Would like thinner, lighter lenses
- Reduction of glare
Other (Please Describe):
Purchasing Plans
Do you plan to purchase any of the following?
- New Eyeglasses
- Prescription Sunglasses
- Non-prescription Sunglasses
- Computer Eyeglasses
- Reading Eyeglasses
- Sport Eyeglasses
- New Supply of Contact Lenses
Other (Please Describe):
Interests
Are you interested in any of the following?
- New contact lens fitting
- New technology or more Comfortable contact lenses
- One-day use contact lenses
- Contact lenses of a different replacement period
- Contact lenses for safe overnight
- Corneal-reshaping contact lenses
- Vision therapy
- Laser vision correction
Other (Please Describe):
Financial Acknowledgement
Please be advised if you are using insurance benefits for today's visit, this is a contract between you and your insurance company...not Midtown Optometry. If your insurance company has not reimbursed our office in full within 60 days, you will be responsible for payment.
By signing and dating above, you have read and understand your financial responsibility.

Manteca and Midtown Optometry

Patient Information

Insurance Information

Patient Medical History

Family Medical/Eye History

Eye Conditions

Eye Concerns

Vision Concerns

Vision Correction

Computer Demands

Performance & Outdoor

Eyeglass Desires

Purchasing Plans

Interests

Financial Acknowledgement