First Name:

Address:

Welcome to Staarrnann Family Vision CenterProfessional Eyecare with a Personal Touch!

M: Last Name: I prefer to be cal led:

Ciry: State: _Z ip :

Cell Phone: Work Phone:

G e n d e r : M F S S # : E m a i l :

Marital Status: f, Single I Married [ Other Ethnicity (optionalJ: Race [optionalJ:Preferred Language;

Hobbies:

Employer/School: Occupation/Grade:

Home Phone:

Date of Birth:

Communication Preference: femail phone text postalJ

Whom may we thank for referring you to our office?

Emergency Contact: Reiat ionship: Phone:

Primary Physician: Last medical exam: Last eye exam: Where:

Smoking Status: I Current Every Day I Current Some Day n Former f Never

INSURANCE INFORMATION

Vision Insurance: ID # :

ID #rMedical Insurance:

Subscriber Name: Relationship to Patient: Date of Birth:

PERSONAL MEDICAT HISTORY

MAIN RE,ASON FOR VIStrT:

Medications'(including eye drops, birth control pills, vitamins and over-the-counter medicationsl:

For:

For:

For:

For:

For:

For:

For:

For:

For:

For:

Allergies: [] Yes I No I No i<nown medication allergies please lisL

f, No [Yes General {Cancer, Developmental Disability, Trauma, Loss of BloodJ Other:

D No nYes Ears/Nose/Mouth/Throat [Hearing Loss, SinusJ Other:

X t'to IYes Cardiovascular fHigh Cholesterol, High Blood Pressure, Stroke, Heart Diseasel Other:

I No IYes Respiratory [Asthma, Bronchitis, Emphysema, C0pD) Other:

I No IYes Gastrointestinal fChron's, Colitis, Acid Reflux, Colon Cancerl 0ther:

n No IYes Genitourinary fbladder cancer, prostate cancer) 0ther:

I No f,Yes Musculoskeletal [0steoarthritis, Fibromyalgi4 Muscular Dystrophy, Ankylosing Spondyiitis] Other:

n No IYes Skin fEczema, Rosacea, Psoriasis, Acne] 0ther:

tr No IYes Neurologicat (Multiple Scierosis, Epilepsy, Cerebral Palsy, Tumor) Other:

n No rYes Psychiatric IADHD, Depression, Anxiety, schizophrenia) 0ther:

I No !Yes Endocrine [Diabetes, Thyroid Disorder, Hormonal DysfunctionJ 0ther:

tr No IYes Lymphatic/Hematological [Anemia, Leui<emia, Bleeding Disorder] Other:

n No IYes Allergic/Immunologic (seasonal, HIV/AIDS, Rheumatoid Arthritis, Lupus, Neurofibromatosisl 0ther:

X No IYes Eyes flnjuries, Surgeries, Glaucoma, Macular Degeneration, Cataracts, Lazy EyeJ 0ther:

tr No nYes Other

Have you ever had general surgery? [ Yes f No please List:

Have you ever had eye surgery? n Yes I No please List:

Do you wear contacts? f Yes X Irlo Type:

Alcohol Use? [ None f Social lModerate

Are you currently pregnant or nursing? [ yes

Are you interested in contacts? DYes INo LASIK? f Yes INO

Narcotic/Drug Use? nNone [Jsocial IDependencef Excessive

trNo

I Blurred Visionf Itching EyesI F]oatersI Poor Night Vision

f Double VisionI Dry Eyesf FlashesI Poor Coior Vision

f Eye Strainf Red Eyes

I Eye Painn Watery Eyes

I Burning EyesI Light SensitivityI Crossed Eyes

PERSONAL EYE HISTORYAre you currently or have you ever experienced any of the following problems?

I Headaches/Migraines f Loss of Visionn Droopy Eyelid D Other:

FAMTLY HISTORYHas anyone in your family (grondparents, siblings, children) been diagnased with the foltowing:

n Cataractf Diabetes

lGlaucoma I Macular Degeneration n Retinal Detachment f] Blindnesstr High Blood Pressure f High Cholesterol [] Cancer I Thyroid Condition

FTNANCIAL RESPONSIBILITY & INSURANCE AUTHORIZATION

staarmann Family Vision Center will file insurance claims for all insurance compa[ies with whom we have an active conFact with. lf we arean out-of-network_provider for your insurance plan, we will provide you will all necessary paper.work so that you maysubmit to yourinsurance carrier for reimbursement, lt is your fesponsibility to klowyour insurance companys coverage al]; limitations. you will beresponsible for anyportion offees not covered or not paid by your insurance company.

AUTHoRIZATIoN: I autiorize staarmann Famllyvision center to release any necessary informadon required for insuranceprocessing. I agree to pay in fult at the time of service all copal's, deductibles, co.in$rrances and not cov;red iiems as determinedby my insurance company,

Patient flegal guardian if under 1B): Date:

PRIVACY POLICY ACKNOWLEDGEMENT

I acknowledge that I have been ofered a copy oftjre'Notice ofPrivacy Practices'from Staarmann Familv vlslon center.

Patient (legal guardian if under 1Bl: Date:

THAI$K YOU

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*i i te* Like and Recommend us on Facebook todav!

Mother 's name:

Any compiications during pregnanc.v or birth? [ yes x NoAny deveiopmentai deiays? D yes I tto

IF PATIENT IS 1B OR UNDER, PLEASE COMPLETE:

Father's name:

Do you have concerns with your chi id's school performance? n yes n No

is this chi ldrs school work [check oneJ I above average

Has your chi ld ever worn spectacies? [ yes I No

Ha.s your chi id ever had eye surgery? I yes I No

Is your chi jd talcin g any medication? I yes I No

Do any rejat ives have serjous eye problems? [ yes I No

Has your chi ld suffered serious heaith problems? f, yes I No

Has your chi id's speech or hearing been tested? [ yes tr No

Has your child ever had any form of vision therapy? [ yes r No

Have any forms of remediarion been aftempted? [ yes D ruo

Does this chi ld dif fer greatly from your othcr chi ldren? n yes D No

tr belowaverage I average o

tr Very sloppy worl<

tr Very neat work

I Reading problerns

I Math problenrs i

I Speil ing pr-oblems

I Writing problems

I Perceptual problems

I I-leadaches

I Squinting

I Eye pain

Patient Symptoms Iplease chec]< all that applyl:

I Avoidance of near work

I Poor reading compre l rens ion

f Red eyes after near work

I Loses piace while reading

I Llead t i l t or turn

f Light bothers eyes

I Reverses words, letters

lshort affention span

! FIolds reading ciose

f, Eyes turn in/out

I Blurred vision

I Double v is ion

I Difficulty remembering

I Uses fingers to read

I Awlrwardness

I Confuses right and ieft

I Laci<s rnotivation

I Hyperactivity

E Easily distracted

n Easily frustrated

lfyou would like our o@mination results Lo be reported to anyone (pediatricion, teacher, school nurse, psychologist, etc.), please provide thefollowing infornqtion and sign the release form below.

Name:0ccupation/Posit ion:

Address;Phone: D - , , .

I ' d .

Name:0ccupation/Posit ion:

Address:Phone:

I authorize t}te release of inforrnation to the individuals listed:

S ignature:Relat ionship:

Fax:

Date;