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Walden Eye Care and Family Center
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2017-07-06T01:14:30+00:00
Walden Eye Care and Family Eye Center
Today's Date
MM slash DD slash YYYY
Name
*
First
M.
Last
Nickname
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone
Cell Phone
Email
Date of Birth
*
MM slash DD slash YYYY
Social Security Number
If using insurance to pay for any part of this visit please specify below:
Vision/Medical Insurance
Supplement
What is your reason for today's visit?
Are you interested in new glasses today?
Yes
No
Are you interested in contacts today?
Yes
No
Are you a current contact lens wearer?
Yes
No
Are you interested in sunglasses today?
Yes
No
Are you currently pregnant or nursing?
Pregnant
Nursing
Neither
Any hobbies or tasks you perform that you would like a different pair of glasses for?
Yes
No
Since yes, please describe:
Have you ever had an eye injury or surgery?
Yes
No
List All Current or Past Eye Diseases, Eye Injuries, or Eye Surgeries
Do you currently take any eye medications?
Yes
No
List All Eye Medications You Are Taking:
Please list any Medication Allergies, or type N/A if none:
Dilation
Dilation of the pupils allows the doctor to obtain a more thorough view of the retina. Therefore, it is highly recommended that the pupils be dilated. The procedure entails using eye drops that will increase your pupil size. The most common side effects include sensitivity to light, decreased near vision and glare. It will take anywhere from 15-30 minutes for your pupils to dilate and side effects will last anywhere from 2-4 hours. If you choose to be dilated, it may help to wear your sunglasses after leaving the office. Any retinal problems that are not found should you choose not to be dilated, will not be the doctor's responsibility. The doctor will be happy to discuss dilation with you during your exam.
I understand the importance of dilation and...
*
I do want my eyes dilated
I do NOT want my eyes dilated
Authorization and Release
Your insurance is a method for you to receive reimbursement for fees you have paid to the optometrist for the services rendered. Having insurance is not a substitute for payment. Many companies have fixed allowances or percentages based on your contract with them not with our office. It is your responsibility to pay in advance for the deductible, coinsurance, or any other balances not paid by your insurance. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine benefits or the benefits payable for related services. This assignment will remain in effect until revoked in writing. A photocopy of this assignment is considered to be valid as the original. By signing this statement, you agree to be financially responsible for all charges.
Patient or Parent/Guardian Signature
Personal Medical History: Please check ALL conditions for which you are being treated, or take medications for.
Constitutional:
Developmental Disabilities
Cancer
Fatigue Syndrome
None
ENT:
Hearing Loss
Sinusitis
Dry Mouth
Laryngitis
None
Psych:
Depression
Attention Deficit
Anxiety Disorder
Bipolar Disorder
None
Neuro:
Multiple Sclerosis
Epilepsy
Cerebral Palsy
Tumor
Stroke/CVA
Migraine
Autism
None
Endo:
Type 2 Diabetes
Type 1 Diabetes
Thyroid Dysfunction
Hormonal Dysfunction
None
Respiratory:
Cigarette Smoker
Asthma
Bronchitis
Emphysema
Chronic Obstruction (COPD)
Sleep Apnea
None
GI:
Crohn's
Colitis
Ulcer
Acid Reflux
Celiac Disease
None
Cardiovascular:
High Blood Pressure
Congestive Heart Failure
Heart Disease
Vascular Disease
Stroke/CVA
None
Musc/Skel:
Osteoarthritis
Arthritis
Fibromyalgia
Muscular Dystrophy
Ankylosing Spondylitis
Osteoporosis
Gout
None
Hem/Lymph:
Anemia
Large - Volume Blood Loss
Ulcer
High Cholesterol
None
Integ:
Eczema
Rosacea
Psoriasis
Herpes Simplex/Cold Sores
Herpes Zoster/Shingles
None
Allergy/Imm:
Drug Allergies
Environmental Allergies
Rheumatoid Arthritis
Lupus
Sjogren's Syndrome
None
Tuberculosis
HIV/AIDS
Hepatitis
None
GU:
Kidney Disease
Prostate Disease/Cancer
STD-Herpetic/Chlamydia
Benign Prostate Hypertrophy
Herpes
Chlamydia
None
Do You Drink Alcohol?
*
Socially
Daily
Never
Do You Use Tobacco Products?
*
Current
Previous
Never
Have you ever been diagnosed with:
Cataracts
Glaucoma
Retinal Detachement
Lazy Eye/Amblyopia
Macular Degeneration
Dry Eyes
Strabismns/Eye Turn
Retinal Hole
Blindness
Other
None
What were you diagnosed with?
Family History (Family History includes your parents, siblings, and your children)
*
Cancer
High Blood Pressure
Diabetes Type 1
Diabetes Type 2
Thyroid Hyper
Thyroid Hypo
Cataract
Glaucoma
Macular Degeneration
None of the Above
What relation do they have to you?
E.g. Mother, Father, Brother, Sister, Son, Daughter
What relation do they have to you?
E.g. Mother, Father, Brother, Sister, Son, Daughter
What relation do they have to you?
E.g. Mother, Father, Brother, Sister, Son, Daughter
What relation do they have to you?
E.g. Mother, Father, Brother, Sister, Son, Daughter
What relation do they have to you?
E.g. Mother, Father, Brother, Sister, Son, Daughter
What relation do they have to you?
E.g. Mother, Father, Brother, Sister, Son, Daughter
What relation do they have to you?
E.g. Mother, Father, Brother, Sister, Son, Daughter
What relation do they have to you?
E.g. Mother, Father, Brother, Sister, Son, Daughter
What relation do they have to you?
E.g. Mother, Father, Brother, Sister, Son, Daughter
Please list all medications you are taking:
Include the Dose, and All vitamins and Supplements.
Please Initial on line Below
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