Download Pacific Eye Care Optometry

EyeWish Optometry
“You will see the difference”
Welcome to our office! Please fill out the following. Your
responses will be treated as confidential medical information.
Do you have sunglasses that filter 100% UVA & UVB rays?
Name (Last, First, M.I.) ___________________________________
Are you bothered by glare or reflection, particularly when driving
Nickname ______________________________ Gender________
at night?
DOB (MM/DD/YY) _______________________
□ Yes
□ No
□ Not Sure
□ Yes
□ No
Age ___________
□ Yes
□ No
Home address __________________________________________
Do you wear contact lenses?
City _____________________ State _______ Zip _____________
If yes, which type? (Check one) □ Soft □ Hard Gas Perm.
Home phone (
_____ )__________________________________
Other__________________________________________________
Work phone (
____ _ )__________________________________
Lens Brand/Powers ______________________________________
Cell phone ( ____
)____________________________________
Average hours worn/day _________________________________
Email address __________________________________________
Cleaning/disinfection solution(s)___________________________
How do you prefer to be contacted?
How often do you sleep in your lenses?_____________________
□ Home
At what age did you first start wearing contacts?_____________
□ Work
□ Cell
□ Email
Height_______________ inches
Race___________________
Weight________________ lbs.
Ethnicity____________________
Do you experience any of the following eye symptoms?
Preferred Language______________________________________
(Check all that apply)
Employer___________________ Occupation_________________
□ Burning
□ Itching
□ Tearing/watering
□ Pain
Hobbies _______________________________________________
□ Eyestrain
□ Floaters
□ Headaches
□ Glare
□ Blurry Vision
□ Light flashes
□ Light Sensitivity
□ Double vision
How did you learn about our office? _______________________
□ Irritation/Foreign body sensation
Vision Insurance (check one):
□ None
□ MES
□ Blue View Vision
□ Davis Vision
Have you ever had any eye injuries or surgeries to your eyes?
□ VSP
□ Medicare
□ Yes
□ Other
□ No
If yes, please list and indicate which eye(s) and the approximate
Name of insured : ________________________________________
date(s).
Insured's DOB ____/_____/_____ SSN __ __ __ -__ __ -__ __ __
_______________________________________________________
Relationship to insured:
_______________________________________________________
□ Self
□ Spouse/Partner
□ Child
Who/where is your primary care doctor or internist?
□ Other
Medical Insurance _______________________________________
_______________________________________________________
□ PPO □ HMO
When was your last physical exam with your primary care
Name of insured (Last, First) _______________________________
doctor? ________________________________________________
ID # ________________________
Emergency Contact:
Are you being followed by a doctor for any medical condition(s)?
□ Yes
□ No If yes, please list
_______________________________________________________
Name__________________________________________________
_______________________________________________________
Phone ( _
)___________________________________________
Relationship to patient ____________________________________
Do you use a computer?
□ Yes
□ No
How many hours (average) per day? ________________________
Eye and Medical History
Do you or any of your relatives have any of the following?
What is the reason(s) for your visit here today?
□ Glaucoma? Who? _______________________________________
_______________________________________________________
□ Cataracts? Who? _______________________________________
Last Eye Exam (Date, Doctor) ______________________________
□ Macular Degeneration? Who? _____________________________
Do you currently wear glasses?
□ Yes
□ No
□ Eye Injury? Who? _______________________________________
Would you like thinner or lighter eyewear?
□ Yes
□ No
□ Retinal Disease / Detachment? Who? _______________________
Would you rather not wear glasses?
□ Yes
□ No
□ Blindness? Who?________________________________________
09/30/2014
EyeWish Optometry
“You will see the difference”
□ Strabismus (eye turn)? Who? ______________________________
Do you have any allergies to medications? □ Yes
□ No
□ Ambylopia? Who? _______________________________________
If yes, please list
□ Diabetes? Who? ________________________________________
_______________________________________________________
□ Dry Eye? Who? _________________________________________
_______________________________________________________
□ Cancer? Who? _________________________________________
_______________________________________________________
□ Heart Disease? Who? ____________________________________
□ Hypertension? Who? ____________________________________
Have you ever had an allergic reaction to drops used in an eye
□ High Cholesterol? Who? _________________________________
exam?
□ Yes, ______________________________ □ No
□ Kidney Disease? Who? __________________________________
□ Yes
□ No
□ Stroke? Who? _________________________________________
Do you have seasonal allergies/hay fever?
□ Thyroid Condition? Who? ________________________________
Do you have any other allergies?
□ Other? Who? __________________________________________
If yes, please list here:_____________________________________
□ Yes
□ No
_______________________________________________________
Do you smoke?
□ Current
□ Former
Do you drink alcohol? □ Socially
□ Yes
□ Never
_______________________________________________________
□ No
Please initial and date at every visit:
Please list all of the medications including eyedrops you are
currently taking, both prescription and over the counter:
Date_______________ Date______________ Date_____________
Date_______________ Date______________ Date_____________
_______________________________________________________
_______________________________________________________
Date_______________ Date______________ Date_____________
_______________________________________________________
ACKNOWLEDGEMENT
OF
NOTICE OF PRIVACY PRACTICES
The law requires that EyeWish Optometry make every effort to inform you of your rights related to your personal health
information. By my signing below, I acknowledge that (PLEASE CHECK ONLY ONE):

I have read or had explained to me EyeWish Optometry’s Notice of Privacy Practice and agree to continue my care
with EyeWish Optometry under said terms.

I was given the opportunity to read EyeWish Optometry’s Notice of Privacy Practices and declined but wish to
continue my care with EyeWish Optometry under the terms of EyeWish Optometry’s privacy policies.

I have read or had explained to me EyeWish Optometry’s Notice of Privacy Practice and do not wish to continue my
care with EyeWish Optometry under said terms.

The Notice of Privacy Practice could not be read due to the emergent nature of the care of other reason described as
_____________________________________________________________________________________________
I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.
Patient_____________________________
Date______________________________
If you are signing as a personal representative of the patient, please indicate your relationship
Representative_______________________
Relationship to Patient_________________
09/30/2014