TSO Keller

Vista Eye Associates

WELCOME TO OUR OFFICE
Today's Date*
MM slash DD slash YYYY
Patient Information
Name*
First MI Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone*
Daytime Phone
Email Address
Do you agree to receive email communications?
- Yes
- No
Patient's SSN
Date of Birth*
MM slash DD slash YYYY
Sex
- M
- F
Race
Marital Status
Employer
Occupation
How were you referred to our office?
Primary Insurance
Please bring all medical and vision insurance cards with you to your appointment.
Insurance Company Name
Insured's Name
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Last 4 of Primary Cardholder’s Social Security
Secondary Insurance Company Name:
Secondary Insurance Identification Number:
Your Eye Health Information
When was your last eye exam?
Where did you get your last eye exam?
Who is your primary care physician?
Glasses/Contact Lens History
Do you wear glasses?
- Yes
- No
Any problems with your current contact lenses or glasses?
Do you need a prescription for contact lenses?
- Yes
- No
Have you ever tried contact lenses before?
- Yes
- No
Do you currently wear contact lenses?
- Yes
- No
What brand of contact lenses do you wear?
How often do you throw your contact lenses away?
Do you sleep in your contact lenses?
- Yes
- No
If yes, how often do you sleep in them?
What brand of solution do you soak your lenses in?
Please check off all that apply to you.
- I am having blurry vision with my current contact lenses
- I am having problems with the comfort of my current contact lenses
- I am having dryness with my current contact lenses
- I am interested in refractive laser surgery (LASIK)
- Concerns about eye bags, droopy eyelids, fine lines/wrinkles around the eyes
Patient Medical History
Please check off any current conditions you suffer from.
- Tired Eyes
- Computer Eye Strain
- Burning
- Dryness
- Sandy or Gritty Feeling
- Watery Eyes
- Itching
- Redness
- Mucous Discharge
- Eye Pain and/or Soreness
- Foreign Body Sensation
- Infection of Eye or Lid
- Drooping eyelid(s)
- Blurred Vision at Distance
- Blurred Vision at Near
- Fluctuating Vision
- Trouble Seeing at Night
- Glare/Light Sensitivity
- Haloes
- Double Vision
- Headaches
- Floaters or Spots
- Flashes of Light
- Loss of Vision
- Loss of Side Vision
Have you ever had any of the following eye conditions):
Glaucoma
- Yes
- No
Macular Degeneration
- Yes
- No
Cataracts
- Yes
- No
Retinal Detachment
- Yes
- No
Crossed Eye/Eye Turn (Strabismus)
- Yes
- No
Lazy Eye (Amblyopia)
- Yes
- No
Corneal Abrasion
- Yes
- No
Eye Infections
- Yes
- No
Iritis/Uveitis
- Yes
- No
Other Eye Conditions:
Please list all medical conditions past or present (Diabetes, High Blood Pressure, High Cholesterol, Heart Problems, Arthritis, Asthma etc.)
Current Medical Conditions:
Past Medical Conditions:
Please list all hospital surgeries you have ever had:
Please list all eye surgeries/eye injuries you have ever had and when you had them:
Is there a family medical history of any of the following (blood relatives only):
Diabetes
- Yes
- No
Relationship: (Whom; Mother's or Father's side?)
High Blood Pressure
- Yes
- No
Relationship: (Whom; Mother's or Father's side?)
Heart Problems
- Yes
- No
Relationship: (Whom; Mother's or Father's side?)
Cancer:
- Yes
- No
Relationship: (Whom; Mother's or Father's side?)
Glaucoma
- Yes
- No
Relationship: (Whom; Mother's or Father's side?)
Macular Degeneration
- Yes
- No
Relationship: (Whom; Mother's or Father's side?)
Retinal Problems
- Yes
- No
- Third Choice
Relationship: (Whom; Mother's or Father's side?)
Please list all prescription and over the counter medications you take (including vitamins and birth control):
What are you taking these medications for?
Please list any eye drops you are currently using and what use them for (Ex- Refresh/Systane):
Please list all drug allergies you have:
Do you drink alcohol?
Do you smoke?
If Yes, How many packs per day?
How many years have you been smoking?
•If you have any comments you would like to add, please enter them here:
Authorized Access/Policies/Insurance/HIPPA
Please list anyone authorized to have access to your medical records including but not limited to: prescriptions, exam records, insurance explanation of benefits, appointment history and statements.
Signature*
By signing this form, I consent to treatment for myself or on behalf of the Minor for which this information pertains. I give permission for the doctor/s to examine, diagnose and initiate treatment as deemed appropriate. I further attest that if I am signing on behalf of Minor that I am the Parent or Legal Guardian of the Minor and have the authority to authorize care and treatment.
CONTACT LENS FITTING & FOLLOW-UP POLICY
Patient, Parent or Guardian Signature*
Consent: I understand that there is a risk involved with wearing contact lenses. I have read the above information and have been trained in the handling and care of my contact lenses and am aware of potential complications.
Contact Lens Prescription Signed Acknowledgment Form
Included below is important information to review prior to receiving your contact lens prescription.
The Centers for Disease Control and Prevention (CDC) makes clear, "Contact lenses can provide many benefits, but they are not risk-free-especially if contact lens wearers don't practice healthy habits and take care of their contact lenses and supplies. If patients seek care quickly, most complications can be easily treated by an eye doctor. However, more serious infections can cause pain and even permanent vision loss, depending on the cause and how long the patient waits to seek treatment." The CDC recommends the following for contact lens wearers: ✓ Schedule a visit with your eye doctor at least once a year. ✓ Take out your contacts and call your eye doctor if you have eye pain, discomfort, redness, or blurry vision. ✓ Understand that eye infections that go untreated can lead to eye damage or even blindness. The Food and Drug Administration (FDA) indicates: "To be sure that your eyes remain healthy you should not order lenses with a prescription that has expired or stock up on lenses right before the prescription is about to expire. It's safer to be re-checked by your eye care professional. "3 Symptoms of Eye Infection include: Irritated, red eyes Worsening pain in or around the eyes—even after contact lens removal Light sensitivity Sudden blurry vision Unusually watery eyes or discharge • Sign below to acknowledge that you were provided with a copy of your contact lens prescription at the completion of your contact lens fitting.
Signature
Health Information Protection
Please sign to acknowledge that you have read and acknowledge the privacy policy. https://www.vistaeyeassociates.com/notice-of-privacy-practices*

Vista Eye Associates

WELCOME TO OUR OFFICE

Patient Information

Primary Insurance

Your Eye Health Information

Glasses/Contact Lens History

Patient Medical History

Have you ever had any of the following eye conditions):

Please list all medical conditions past or present (Diabetes, High Blood Pressure, High Cholesterol, Heart Problems, Arthritis, Asthma etc.)

Is there a family medical history of any of the following (blood relatives only):

Authorized Access/Policies/Insurance/HIPPA

CONTACT LENS FITTING & FOLLOW-UP POLICY

Consent: I understand that there is a risk involved with wearing contact lenses. I have read the above information and have been trained in the handling and care of my contact lenses and am aware of potential complications.

Contact Lens Prescription Signed Acknowledgment Form

Health Information Protection