Target Optical

Target Opticaladmin2017-07-06T01:14:32+00:00

Target Optical

Preferred Provider
Patient Information
Name
First Last
Cell Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation
Account Responsible Information
Information about person responsible for bill. Only need address if different than patients.
Relationship to Patient
Salutation
Name
First Last
Date of Birth
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Information
Type Insurance Company under Company Name. Eyemed patients have no ID #, VSP ID last 4 of primary SS #.
Company Name
Insured person employer/school
Insured person relationship
Name
First Last
Date of Birth
MM slash DD slash YYYY
Insured person gender
Insurance number
Medications
If no medication used, go on to next section, BUT PLEASE LIST ANY YOU ARE TAKING.
Name Date Started
Allergeries
If NO Alergeries, go on to next section.
Name Reaction Severity
General History
Primary Care Phyisican
Last Visit
Do you work on a computer?
- Yes
- No
Hours per day?
Ocular History
Last eye exam
Patient's Health History
Check all that apply, or "Negative" if the patient has none of the conditions listed
Eye
- Negative (I have no known medical eye problems)
- Amblyopia (lazy eye)
- Cataract
- Glaucoma
- Eye Surgery - Cataract
- Eye Surgery - Cornea
- Eye Surgery - Refractive (Lasik, RK, etc.)
- Eye Surgery - Retinal
- Eye Surgery - Retinal
- Eye Surgery - Strabismus (eye turn)
- Macular Degeneration
- Retinal Disease
- Strabismus (eye turn)
- Other
General/Constitutional
- Negative (I have no general health issues)
- Fibromyalgia
- Cancer
- Other
Ears/Nose/Mouth/Throat
- Negative (I have no known ear/nose/throat problems)
- Hay fever
- Dry mouth
- Sore throat
- Earache
- Other
Cardiovascular
- Negative (I have no known heart or vascular problems)
- High Blood Pressure
- Heart Disease
- High cholesterol
- Arrhythmia
- Murmur
- Pacemaker
- Other
Respiratory
- Negative (I have no known breathing problems)
- Asthma
- Bronchitis
- Emphysema
- COPD
- Lung cancer
- Tuberculosis
- Other
Gastrointestinal
- Negative (I have no GI problems)
- Gall bladder disease
- Acid Reflux
- Jaundice
- Other
Genitourinary
- Negative (I have no urinary/kidney problems)
- Dialysis
- Kidney disease
- Other
Musculoskeletal
- Negative (I have no known musculoskeletal problems)
- Rheumatoid Arthritis
- Osteoporosis
- Muscle Pain
- Joint Pain
- Back Pain
- Swelling of joints
- Other
Integumentary
- Negative (I have no skin problems)
- Skin Rashes
- Dry Skin
- Psoriasis
- Other
Neurological
- Negative (I have no skin problems)
- Dizziness/vertigo
- Epilepsy
- Seizures
- Migraines
- Numbness
- Paralysis
- Multiple Sclerosis (MS)
- Other
Psychiatric
- Negative (I have no known psychiatric problems)
- Anxiety
- Depression
- Other
Endocrine
- Negative (I have no known endocrine problems)
- Diabetes (Type I)
- Diabetes (Type II)
- Hyperthroid
- Hypothroid
- Addison's Disease
- Cushing's Syndrome
- Grave's Disease
- Hashimoto's
- Pituitary Disorder
- Other
Lymphatic/Hematological
- Negative (I have no known blood/lymphatic problems)
- Anemia
- Bleeding Problems
- Ease of bruising
- Leukemia
- Other
Allergic/Immunologic
- Negative (I have no known allergies or immune problems)
- Seasonal Allergies
- Chronic Allergies
- Arthritis
- Lupus
- HIV/AIDS
- Other
Family Health History
(cancer, diabetes, heart, hypertension, thyroid, glaucoma, cataracts, macular degeneration, etc.)
Disease Relationship Details

Name	Date Started

Name	Reaction	Severity

Disease	Relationship	Details

Target Optical

Patient Information

Account Responsible Information

Insurance Information

Medications

Allergeries

General History

Ocular History

Patient's Health History

Family Health History