Foley Vision Center
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New Adult Patient Form

GENERAL INFORMATION
Full Name:
Preferred Name:
Birth Date:
SSN (last 4 digits):
Address:
City:
State:
Zip:
Phone (hm):
Phone (cell):
Okay to text
Phone (work):
Email:
Employer:
Current Occupation:
Spouse:
Please fill out below if Insurance has changed since your last visit...
Insurance Company Name (Vision):
Name of Primary Member:
ID #:
Insurance Company Name (Medical):
Name of Primary Member:
ID #:
Primary Care Physician:
Preferred way to contact you: Email
Home Phone
Cell Phone
Work Phone
Referred By:
Race:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiin or Other Pacific Islander
White
Unknown/Decline to Provide
Ethnicity: Hispanic or Latino
Not Hispanic or Latino
Decline to Provide
Preferred Language: English
Spanish
Other:

Per the Health Care Act we are required to record your height and weight at each visit.
Height: Weight:

Patients with Insurance: At the time of treatment, patients are expected to pay their estimated charges. An estimate of cost will be provided to you at the time of your appointment. Insurance portion is only an estimate and any balance remaining after insurance payment is patient's responsibility.

Patients without Insurance: Patients without insurance are required to pay the charges in full at the time service is provided. A total cost will be provided to you at the end of your appointment.

Do you plan on purchasing new glasses today? Yes No If RX changed
Reason for Today's Visit:
CHIEF COMPLAINTS TODAY (or over the last week)
Allergies
Blurred Vision Distance
Blurred Vision Near
Burning/Stinging
Discharge
Double Vision
Dryness
Eye Strain/Fatigue
Floaters/Spots
Flashes
Glare/Sensitivity to Light
Foreign Body Sensation
Headache
Itching
Loss of Vision
Loss of Side Vision
Pain/Discomfort
Redness
Scratchy/Gritty
Watering/Tearing
GLASSES
Do you wear glasses? Yes No
Single Vision
Progressive
Bifocals
Trifocals

For:
Near
Distance
Both
Any Problems?
CONTACTS
Do you wear Contacts? Yes No
Full Time
Occasional
Rarely


Type of contacts?
Daily Wear
Extended Wear
Soft Toric
Gas Permeable
Bifocal/Progressive
What cleaning solution do you use?
Average Wear Time: hours.
Wear Time Today: hours.
Any Problems?
OCULAR SURFACE DISEASE SURVEY
Never Slight Moderate Severe
Do your eyes ever feel or do you experience:
Gritty or Sandy sensation?
Pain or soreness?
Fluctuating vision?
Occasional Tearing?
Blurred vision while reading or computer use?
Discomfort in windy conditions?
Discomfort in Heating/Air Conditioned areas?
ALLERGY SURVEY
Do you EVER suffer from red eyes, itchy eyes, watery eyes, or swollen eye lids?
Yes No
Do you EVER use over-the-counter or prescribed eye drops (i.e. VISINE A, VISINE AC, OPCON A, etc.) to treat red eyes, itchy eyes, watery eyes, or swollen eye lids?
Yes No       If yes, please list:
Do you take any prescribed or over the counter medications like CLARITIN, ALLEGRA, or ZYRTEC for your allergies?
Yes No       If yes, please list:
MEDICAL HISTORY
Do you have any allergies to medications?
Yes No
If yes, please explain:
Other Allergies (foods, pollens, etc.):
List any medications you take:
Rx or OTC/SupplementsCondition
Do you currently take any of the following medications? (Please check all that apply)
Birth Control Pills
Beta Blockers
Diuretics (Lasix)
Active bladder therapy
Antihistamines
Antidepressants
Accutane (even previously)
Hormone Replacement Therapy
Have you ever had eye surgery (LASIK, PRK, Cataract Surgery, other)?
Yes No       (please specify)
Are you interested in LASIK surgery at this time?
Yes No
OCULAR:
Self Family Who?
Amblyopia (Lazy eye)
Blindness
Cataract(s)
Color Deficiency
Glaucoma
Macular Degeneration
Ptosis (Drooping Lid)
Retinal Detachment
Retinal Tear
Strabismus (eye turn)
Other:
MEDICAL:
Self Family Who?
Androgen Deficiency
Arthritis
Acne Rosacea
Diabetes
Cancer
Facial Herpes Zoster (Shingles)
Heart Disease
Hepatitis C
High Blood Pressure
Kidney Disease
Lupus
Migraines
Sarcoidosis
Sleep Disorders
Stroke
Thyroid Disease
Other:
SOCIAL HISTORY
Do you drive?
Yes No
If yes, do you have visual difficulty when driving?
Yes No
If yes, please describe:
What type of work do you do?
Do you go to school?
Yes No
If yes, where and grade level/field of study?
Do you play any sports?
Yes No
If yes, what type and amount:
Other forms of exercise?
Do you have any hobbies?
How many hours per day do you:
Work on a computer?
Read?
Watch TV?
Play Video Games?
Our goal is to provide the best, most complete, up-to-date care available. Our philosophy is preventive and developmental in approach. To provide this service in the most efficient manner, please be aware of the following office policies:
  • Fees for services are due at the time those services are rendered.
  • Payment in full at time of ordering.
  • We reserve the right to charge for missed appointments not canceled in advance.
  • Vision Therapy patients must notify us of absences in advance.
  • There is a charge for written reports.
  • Responsibility for payment is the patient's. Insurance agreements are between the company and the patient. We will assist with proper forms but require reimbursement from patients.
Signed (type your name):
Date: