Total Vision Family Eye Care

Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Social Security Number*
Gender*
- M
- F
Insured's Name
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Which phone number would you prefer we use to contact you?*
- Home
- Work
- Cell
Home Phone:
Work Phone:
Cell Phone:
Emergency Contact:*
Email
Marital Status*
- Single
- Married
Insurance Information
*We must have a copy of all insurance cards on the day of service*
Primary Medical Insurance
Secondary Medical Insurance
Vision Insurance
Insured's Social Security Number
Insured's Birth Date
Insured's Employer
Family Doctor
Family Dr. Clinic/Phone
Family Members
For ease of data transfer, are they patients at this office?
- Yes
- No
NOTICE OF PRIVACY PRACTICES: I/We have been offered a copy of Total Vision Family Eye Care statement on privacy practices.
AUTHORIZATION TO RELEASE INFORMATION: I/We hereby authorize Total Vision Family Eye Care to release any medical or incidental information that may be necessary for medical benefit of in processing applications for financial benefit. This includes but is not limited to my insurance company, Rehabilitation Services, Social Security Administration, and Worker’s Compensation.
CONSENT FOR TREATMENT: I/We hereby authorize Total Vision Family Eye Care to administer diagnostic and medical procedures as may be necessary for proper health care.
OFFICE POLICY ON PAYMENT: I understand that I am responsible for payment of all charges. As a courtesy, my insurance will be billed for me. It is my responsibility to pay any deductible, copay or any other balance not paid by my insurance company. I authorize insurance benefits to be paid directly to the provider.
VISION PLAN COVERAGE: I/We understand that only one vision plan may be used for exam/materials per visit-per patient and that the vision plan to be used must be chosen before the exam occurs and can not change at a later date. If I do not supply my vision plan at the time of services I will be required to pay up front and self-submit on my own.
Signature*
Date*
MM slash DD slash YYYY
CHIEF COMPLAINT*
How can we help you today? In this space please check/explain any signs and/or symptoms you are experiencing. Medical insurance will only cover if there is a medical reason for the exam/test such as loss of vision, headaches, eye pain, eye itching or burning, redness, glaucoma, cataracts, floaters, dry eyes, etc.
- Loss of vision
- Blurred Vision
- Double Vision
- Floaters
- Crossed Eyes
- Flashes of light
- Eye pain/soreness
- Watery eyes
- Sandy/gritty feeling
- Glare
- Light sensitivity
- Tired eys
- Dry eyes
- Red eyes
- Burning/itching
History of Present Illness
Location - Which eye has the problem?
- Right
- Left
- Both
Quality - How is it affecting you?
- Bothersome
- Aware
- Painful
Severity - How severe is the problem?
- Mild
- Moderate
- Severe
Duration - How long have you had the problem?
Timing - Is it new, ongoing, or returning?
- New
- Ongoing
- Returning
Context - Associated with:
- Infection
- Medical Condition
- Injury
- Surgery
Modifiers - Previous treatment?
- Drops
- Medication
Symptoms - Are there associated symptoms?
- Headache
Family History
Has anyone in your family been diagnosed with any of the following (check all that apply):*
- No Problems
- Diabetes
- High Blood Pressue
- Cancer
Has anyone in your family been diagnosed with any of the following eye problems (check all that apply):*
- No Problems
- Glaucoma
- Amblyopia
- Cataracts
- Macular Degeneration
- Strabismus (eye turn)
Lifestyle Survey
Are your eyes sensitive to sunlight?*
- Yes
- No
Problems with reflections and/or glare?*
- Yes
- No
Do you work at a computer?*
- Yes
- No
Want information on thinner/lighter lenses?*
- Yes
- No
Please circle all activities/hobbies that apply to you:*
- Outdoor Sports
- Gardening
- Gaming/Computers
- Music/Art
What is your occupation?
Current Vision
Glasses: Do you currently wear glasses?
If yes, answer the question below; if no, continue to contact lenses section.
- Yes
- No
What type of lenses are in your glasses?
- Single
- Bifocal
- Trifocal
- No-line (Progressive)
Contact Lenses: Do you currently wear contact lenses?
If yes, answer the questions below; if no, continue to past ocular history section
- Yes
- No
What type of contact lenses do you wear?
- Soft
- Rigid
What is the manufacturer/model of your contact lenses?
What are the powers of your contact lenses (if you know)?
How old are your current contact lenses? Please specify months or years.
How often do you replace your contact lenses?
- Daily
- Weekly
- 2 Weeks
- Monthly
- 3 Months
- 6 Months
- Annually
What solution do you use to care for contact lenses?
- Renu
- Optifree
- Clear Care
- Biotrue
- Boston
- Optimum
Review of Systems
Ocular/Eye Problems (check all that apply)
- Inflammatory disorder
- Surgery
- Glaucoma
- Amblyopia (lazy eye)
- Cataract
- Retinal problems
- Macular degeneration
- Strabismus (eye turn)
- Patching
Other ocular/eye problems, if applicable:
Constitutional Problems (check all that apply)
- Cancer
- Fatigue
- Developmental Disability
Other constitutional problems, if applicable:
Ears, Nose, Mouth, Throat Problems (check all that apply)
- Laryngitis
- Dry Mouth
- Hearing Loss
- Sinusitis
Other Ears, Nose, Mouth, & Throat problems, if applicable:
Neurological Problems
- Cerebral Palsy
- Multiple Sclerosis
- Tumor
- Epilepsy
Other Neurological problems, if applicable:
Psychiatric Problems
- Depression
Other Psychiatric problems, if applicable:
Cardiovascular Problems
- Vascular Disease
- Stroke
- Congestive Heart Failure
- Heart Disease
- High Blood Pressure
Other Cardiovascular problems, if applicable:
Respiratory Problems
- Emphysema
- Bronchitis
- Smoker
- COPD
- Asthma
Other Respiratory problems, if applicable:
Gastrointestinal Problems
- Colitis
- Chron's Disease
- Ulcer
Other Gastrointestinal problems, if applicable:
Genitourinary Problems
- Prostate Disease/Cancer
- STD
- Kidney Disease
Other Genitourinary problems, if applicable:
Musculoskeletal Problems
- Ankylosis Spondylitis
- Fibromyalgia
- Muscular Dystrophy
- Osteoarthritis
Other Musculoskeletal problems, if applicable:
Skin Problems
- Rosacea
- Psoriasis
- Eczema
Other Skin problems, if applicable:
Endocrine Problems
- Insulin Dependent Diabetes
- Hormonal Dysfunction
- Thyroid Dysfunction
- Non-Insulin Diabetes
Other Endocrine problems, if applicable:
Blood/Lymph Problems
- Large Volume Blood Loss
- Anemia
Other Blood/Lymph problems, if applicable:
Allergy/Immunologic Problems
- Environmental Allergies
- Rheumatoid Arthritis
- Drug Allergies
- Lupus
Other Allergy/Immunologic problems, if applicable:
Do you smoke?*
- Yes
- No
Do you consume alcohol?*
- Yes
- No
Do you sometimes experience dry eyes?*
- Yes
- No
Prefer not to wear your glasses at times?
- Yes
- No
Interested in newer contact lens technology?
Want information on LASIK vision surgery?
Want a non-surgical option to LASIK?
List any medications you are currently taking:
List any medicine allergies:
List any other allergies:

Total Vision Family Eye Care

Insurance Information

History of Present Illness

Family History

Lifestyle Survey

Current Vision

Review of Systems