PATIENT INFORMATION
INSURANCE INFORMATION
Your eye exam includes much more than just checking your vision. It is of the utmost importance to assure that your eyes are healthy and disease free. In order for Dr. Taylor and/or Dr. Hall to examine your eyes adequately it may be necessary to have additional testing performed during the exam or at another scheduled appointment. Dr. Taylor and/or Dr. Hall will discuss the nature and necessity of these tests with you before performing them. These tests may incur additional fees which may not be covered under your vision insurance, but may be covered under your medical insurance. Therefore, even if you do not currently have vision insurance, please fill out the information below concerning your medical insurance and bring your insurance card to the front desk. If you have any questions or concerns, please feel free to speak with a member of our staff.
Vision Insurance
Medical Insurance
PATIENT COMMUNICATION OPT-IN ACKNOWLEDGEMENT
How would you like best to be contacted when your ordered items have arrived or for appointment reminders?
EYE HEALTH HISTORY
Date of last eye exam:
Name of eye doctor or location:
Interested in learning more about LASIK or other corrective surgical procedures?
MEDICAL HISTORY
Patient Name: (First)
(MI)
(Last)
Preferred Name:
Date of birth: 
SSN#:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Preferred Phone:
Occupation:
Employer:
Email:
​Spouse's name:
or Parent's name(s):
DOB:
Employer:
Name of Insurance:
ID#:
Group:
Are you the primary insured?
(if yes, skip section below)
Name of primary insured:
SSN:
DOB:
Employer:
Relationship to insured:
Street:
City:
State:
Zip:
Home Phone:
Name of Insurance:
ID#:
Group:
Name of primary insured:
SSN:
DOB:
Employer:
Relationship to insured:
Street:
City:
State:
Zip:
Home Phone:
Please check any problems below, as best you can, that you are currently experiencing:
Please mark any of the following symptoms noticed after extended computer/device usage:
Do you currently wear glasses?
If YES, do you wear them: 
What type of lenses do you wear?
What do you like about your current glasses?
What would you change about your current glasses?
Do you currently wear contact lenses?
Please be aware that there is a contact lens fitting fee that may or may not be covered by your insurance. This fitting, by law, has to be updated every 12 months in order to have an active contact lens Rx and be able to order contact lenses.
If you are a current contact lens wearer, please answer the following questions:
What brand or type of contact lenses do you wear?
How old are your current lenses?
How often do you replace your lenses?
What is your normal wear schedule?
hours a day
days a week
Are you having any problems with your current contact lenses?
What brand of solution do you soak and clean your lenses with?
Do your back-up glasses have your current Rx?
If you DO NOT wear contact lenses, please mark any of the following statements that apply to you:
Name of Primary Care Provider (PCP):
PCP's Phone:
Date of last physical:
Preferred Pharmacy:
Pharmacy's Phone:
Cataracts
Glaucoma
Macular Degeneration
Retinal Disease  TYPE:
Crossed Eye/Lazy Eye
Hepatitis  TYPE:
Cancer  TYPE:
Cancer  TYPE:
Cancer  TYPE:
High Blood Pressure
Stroke
High Cholesterol
Diabetes Type I
Diabetes Type II
Heart Condition  TYPE:
Depression
Anxiety
ADHD
Sleep Apnea
Emphysema
COPD
Lupus
HYPERThyroidism (Grave's)
HYPOThyroidism (Hashimoto's)
Arthritis
Epilepsy/Seizures
Parkinson's Disease
Alzheimer's Disease
Shingles
Fibromyalgia
Muscular Dystrophy
Multiple Sclerosis
AIDS/HIV+
Tuberculosis
Other  TYPE:
How long have you been treated for any of the above conditions?
Please describe any major surgeries and the year performed (including any eye surgeries/procedures):
Do you smoke?
If YES, how do you smoke and how often?
Do you drink alcohol?
Are you pregnant?
If YES, how many months?
Gestational Diabetes?
If you are diabetic: How often do you check your glucose levels?
Today's glucose level:
Average glucose level:
A1C and date taken:
ALLERGIES:
MEDICAL:
ENVIRONMENTAL/FOOD:
CURRENT MEDICATIONS Over-the-Counter AND Prescription (Add dosage and frequency):
Clicking 'Submit' below will privately and securely send your information to us in a HIPPA compliant manner.
...
Choosing Text/Email will ensure a quicker response time. Phone calls are made at the end of the day.
Click if no vision insurance
YesNo
SelfSpouseDependent
Click if address and contact info is the same as the patient
Click if no medical insurance
Click if info below is the same as in the left column
SelfSpouseDependent
Text/EmailPhone Call
YesNo
Blurred Vision-Distance
Blurred Vision-Computer
Blurred Vision-Near
Temporary Loss of Vision
Sustained Loss of Vision
Headaches/Migraines
Light Sensitivity
Seeing Flashes
Seeing Floaters
Crossed Eyes/Lazy Eye
Poor Night Vision
Itchy Eyes
Red Eyes
Watery Eyes
Dry Eyes
Burning Eyes
Twitching Eyelid(s)
Dizzy Spells
Blind Spot(s) in Vision
Mucous Discharge
Seeing Halos
Double Vision
Eye Injury
Stye(s)
Blurred Vision
Eyestrain
Headaches
Dry Eyes
Watery Eyes
Glare Sensitivity
YesNo
Full-timePart-timeDistance OnlyNear Only
Single Vision (Distance)Single Vision (Near)Single Vision (Computer)Lined BifocalProgressive
YesNo
Dry out easily
Uncomfortable
Blurry Far Vision
Blurry Near Vision
YesNoI do not have back-up glasses
I have had LASIK or other corrective surgery
I have been told I can't wear contact lenses because I have astigmatism or reading problems
I have worn contacts but stopped due to comfort/vision problems
I have never worn contacts, but would like more information
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YesNo
YesNoRarely
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YesNo
DAD