Patient Information

Thank you for choosing Valley Eye Associates for you eyecare needs. Please complete this form in ink. If you have any questions or concerns, please do not hesitate to ask for assistance. We will be happy to help you.

*All fields with an star are required.

Today's Date*

Name*

Prefix First Middle Last

Sex

Female
Male

SSN

Date of Birth*

Age

Email*

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Cell Phone

Would you like to receive text confirmations?

Yes
No

Preferred Phone Number

Race

African American
Asian
Hispanic
American Indian
Caucasian
Pacific islander

Marital Status

Employer Name & Address

Position/Department

Spouse/Parent's Name

Spouse/Parent's Work/Cell Phone

Student

Yes
No

Name of School

Guarantor (Person Financially Responsible)

If Self: Skip this section.

Name

First Last

Relationship to Patient

Parent
Spouse
Other

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Medical Insurance Information

Primary Insurance

Primary Policy Holder

Member ID

Primary's SS#

Primary's Date of Birth

Secondary Insurance

Primary Policy Holder

Member ID

Primary's SS#

Primary's Date of Birth

Vision Insurance

Vision Insurance Provider

Policy or ID Number

Patient Medical History & Review of Systems

Medical Doctor

Medical Doctor's Phone

Date of Last Physical

Date of Last Eye Exam

Chief Complaint

How can we help you today? In this space, please briefly tell us any signs and symptoms you are experiencing.(Medical insurance will only cover your visit if there is a medical reason for the exam such as loss of vision, headaches, eye redness, eye pain, floaters, dry eye, eye itching or burning, glaucoma, cataracts, etc)

History of Present Illness

Which eye has a problem?

Right Eye
Left Eye
Both Eyes

Does the problem cause vision loss or blur?

Loss
Blur

Did the problem occur suddenly or gradually?

Sudden
Gradual

How severe is the problem?

Mild
Moderate
Severe

Is it worse at any specific distance?

Distance
Near
Both

How long does it last?

Intermittent
Constant

How long has the problem been occuring?

Short Term
Long Term

Are there associated symptoms?

No
Headaches
Nausea

Does anything help the problem?

Nothing helps
Nothing has been tried

Glasses & Contacts

Are you thinking of getting GLASSES today?*

Yes
No

Are you thinking of getting CONTACTS today?*

Yes
No

Do you currently wear glasses?

Yes
No

When do you wear your glasses?

All the Time
Reading/Near Work Only
Computer Work
Work Safety
Distance Tasks Only
Driving
Other

Please Explain

Have you ever worn contacts?

Yes
No

Brand

Contact Lens Solution Used

Are you interested in wearing contact lenses?

Yes
No

What style?

Soft
Gas Permeable
Extended Wear
Bifocal
Color
Disposable
Astigmatic
Unsure

Do you work at a computer or video display terminal?

Yes
No

In which hobbies or sports do you participate?

Medical Information

Please Check any conditions that apply to you:

Allergies (seasonal)
Allergies (environmental)
Drug Allergies (please list below)
Pregnant
Have given birth in last 6 months
Breastfeeding
Sinus Trouble

Do you currently take any medications?*

No
Yes

Please list current medications:

Name, Dosage and Frequency.

Do you have any drug allergies?*

Yes
No

Please list all known drug allergies:

Please list any major surgeries or hospitalizations:

Past Ocular History

Please select all that apply:

Please explain:

Family Ocular/Medical History

Please select all that apply:

Please explain:

Social History

Smoking

No
Yes

Packs a day

Years

Alcohol

No
Social
Occasional
Heavy

Drinks per day:

Review of Systems

Please select all that apply or fill in the blank for those not listed.

Constitutional

Flu
Fever
Fatigue
Headache
Recent Weight Change

Select if you currently have.

Endocrine

Thyroid
Diabetes
Other

Year diagnosed:

Other:

Ears, Nose, Throat

Hearing Problems
Sinus
Throat

Genitourinary

Prostate Problems
Kidney Stones
Hysterectomy

Cardiovascular

Neurological

Stroke
Weakness
Seizure
Multiple Sclerosis

Skin

Rash
Itch
Lesion
Growth/Tumors

Respiratory

Shortness of Breath
Asthma
Emphysema
Cough
Bronchitis
Pneumonia
Tuberculosis

Psychiatric

Dementia
Alzheimer's
Depression
Anxiety
Schizophrenia
Bipolar

Hematologic

Anemia
Sickle Cell
Bleeding Abnormality
Elevated Cholesterol

Gastrointestinal

Heartburn
Bowel Problems
Inflammatory Bowel Disease
Gall Bladder Problems
Hepatitis

Musculoskeletal

Joint Pain
Rheumatoid Arthritis
Back Pain
Fractures
Marfan's Syndrome
Ankylosing Spondylitis

Immunology

Immune Deficiency
Lupus
Sjogren's
Other

Please Explain Other:

Cancer

Yes
No

Type:

HIV Exposure

Yes
No

STD Exposure

Yes
No

Type:

Authorization

I certify that I have read and understood the above information to the best of my knowledge. I certify that the above questions have been accurately answered to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health. I authorize the doctor to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eyecare to third party payers and/or health practitioners.*

Signature of Responsible Party

Date*

Agreement of Responsibility

Please View Our Agreement of Responsibility Here

I have been informed by Valley Eye Associates and the Notice of Privacy Practices (see forms below) which contains a more detailed description of the uses and disclosures of my health information. I have been given the right to review and sign this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that Valley Eye Associates restricts how my private information is used or disclosed to carry out treatment, payment, or health care options. I also understand that Valley Eye Associates is not required to agree to my request restrictions, but if Valley Eye Associates does agree then it is bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, excluding the extent in which Valley Eye Associates has already taken action relying on this consent.*

Signature of Patient (Or Responsible Party)

Date*

Payment Policy

Please View Our Payment Policy Here

I authorize the release of information to determine liability for payment and/or to obtain reimbursement. I understand that if my account is not paid directly, I am responsible for the full amount and may be charged all costs including attorney/collection agency fees incurred with collection of the amount due. I authorize the release of any medical information necessary to process claims and the release of payment to Valley Eye Associates or the physician rendering services.*

Signature of Patient (Or Responsible Party)

Date*