WEL
LCOME TO
T OUR OFFICE!
O
Todayy’s Date
Insurance Infformation
Visionn Insurance
Subsccriber Name
Subsccriber SSN
Subsccriber Birth Date
D
Patient Inforrmation
Last
First
MI
WE
ELCOME TO OUR
O
OFFICE
Streett
City
State
Zip Code
Homee Phone
Work Phone
Patiennt’s SSN
Emplooyer (or Schhool)
Occuppation (or Grrade)
Spousse (or Parentt’s Name)
Spousse (or Parentt’s Work)
Date of
o Birth
Sex M F
Emaill Address
Primaary Medical Innsurance
Subsccriber Name
Subsccriber SSN
Subsccriber Birth Date
D
Do yoou participate in a flex spennding accounnt?
Yes
No
How will
w you settlee your accounnt today?
Cash
Checck
C
Credit
Card
Agee
What is the majorr purpose of this visit?
Any problems
p
witth your curreent contact lenses or
glassees?
Do yoou plan on puurchasing neew glasses tooday?
Y
Yes
No
VERY
Y IMPORT
TANT! NEW
W PATIEN
NTS ONLY:
Y:
Who may
m we thannk for referriing you to ouur office?
Namee of friend orr relative
If not referred, hoow did you ch
hoose our offfice?
Annother Dr.
Inssurance List
Saw
w Sign/Buildding
Newspaper/Radio/TV
Yellow Pages: Which direcctory?
Weeb Page: Whhich Web Sitte?
Othher
Lifestyle Questions
Do yoou……(check
k box if yourr answer is yees)
..woork at a compputer? If yes, please
p
compleete computer
quuestionnaire.
..thiink you might benefit from
m thinner, lighhter lenses?
..haave interest in a “test drive”” of the latestt contact lens
deesigns
..spend time outddoors? How much?
m
__H
Hrs/week
..haave prescriptioon sunwear?
..preefer not to weear your glassses at times?
..waant informatioon on Laser Vision
V
Correction surgery??
..knnow someone who has poor vision due to
t macular
deegeneration, glaucoma,
g
diaabetic retinopaathy, a strokee,
orr other ocular diseases or conditions?
..haave more thann 1 pair of currrent Rx eyew
wear?
..haave children?
..haave family meembers in need of eyecare??
Have you ever exp
perienced, beeen diagnoseed or treated
for an
ny of the folloowing?
Bluurry Vision
Burning
Corneal Abrasions
Cattaracts
A
Croossed eye/Eyee turn
Double Vision
V
Eyee Infections
Eye Injurry
Flaash of light
Floaters/S
Spots
Glaaucoma
Grittinesss
Headaches
Iritis/Uveeitis
Itchhiness
Lazy Eyee
Maacular Degeneeration
Occasionnal dryness
Rettinal Detachm
ment
Sunlight Sensitivity
Trouble seeing
Teaaring
s
at nighht
Unncomfortable glasses
g
Othher eye disordders
Th
he informatioon in this con
nfidential casse history forrm is critical to the evaluaation of yourr vision and health.
h
Pattient Mediccal History
P
Patient
Eyee History
Name of Family Phhysician
Town
Date of
o Last Physiccal Check-up
Date of
o Last Eye Exam
E
By Whom?
W
CURR
RENT MEDIICATIONS (Rx
( or Over the Counter))
(List name
n
of mediccations includ
ding eye dropps, vitamins, &
birth control
c
pills)
Allerggies to medicaations?
If so, what
w medicatiions?
Y
Yes
No
________
y had any surgeries?
s
Y
Yes
Have you
Do youu use cigaretttes/tobacco, alcohol,
a
or othher
substances?
Y
Yes
Have you ever triedd contact lensses?
Y
Yes
No
Do yoou currently wear
w contact lenses?
What kind?
Solutiions used
Y
Yes
No
Are yoou satisfied with
w the visionn and comfortt of your
contacct lenses?
Yes
N
No
c
contact lenses or coloored contact
Wouldd you prefer clear
Cleaar
lensess?
C
Colored
No
No
y ever beeen diagnosed or treated foor the
Have you
No
follow
wing health problems? Yes
Allerggies
Arthrittis
Blood//Lymph
Bronchhitis
Cancer
Cholessterol
Diabettes
Digesttive
Ears/N
Nose/Throat
Endoccrine
Eczem
ma/Rashes
Fatiguue
Feverss
Genitoourinary
High Blood
B
Pressurre
Integuumentary (Skiin)
Kidneyy
Muscle/Bone
Neurological
Psychoological
Respirratory
Sinus
Throatt Infections
Thyroiid
Unusuual weight losses/gains
If youu wear bifocalls, do the linees or head tiltiing bother
you?
Yes
N
No
Family Medicaal/Eye Historry (Check all that apply)
Is therre a family medical
m
historyy of any of thee following:
No
Yees (Please cheeck boxes)
Relationship
(Motheer’s or Father’’s side)
Blindnness
Cataraacts
Corneeal Problems
Diabeetes
Glauccoma
Heart Disease
Lazy Eye
E
Macullar Degenerattion
Retinaal Problems
Our Mission
M
The mission of Infinity Eye Care andd Low Visioon
Rehabbilitation Cen
nter is to
• provide thee absolute higghest quality and
a level of
care
• educate ouur patients about their uniqque visual
system andd how it relatees to their oveerall health
a
s
• offer quality services annd the latest advancements
in materialls
• provide leggendary custoomer service
• stay at the forefront
f
of vision
v
care annd eye health
care so thaat our family of
o patients caan achieve andd
maintain thheir highest leevel of visuall potential to
improve thheir quality off life.