Date

Patient Name

First Last

Address

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

Mobile

home

work

Employer (or School)

Occupation (or Grade)

Date of birth

Age

Sex:

Marital Status:

What are your major concerns (and or) needs that you would like addressed today?

Any problems with your present contact lenses or glasses?

How will you settle your account today?

Cash

Check

Credit Card (MasterCard/Visa/Discover/Amex)

Care credit

Insurance Information

Medical Insurance co.

Subscriber Name

First Last

Relationship to Patient

ID#

Group#

Hidden

ID#

Hidden

Group#

Subscriber Birth Date

Subscriber Employer

Financial Policy Release of Information Privacy Practices Acknowledgement

The Vision Development Team extends the courtesy of filling out a medical insurance claim form for you to submit to your insurance company for reimbursement to you.
I understand that I will be required to pay for services at the time rendered.
I authorize Alexandar Andrich, OD, FCOVD to release any information required by my insurance company.
I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Signature

Date

(Guardian signature required if patient is under 18)

VERY IMPORTANT! NEW PATIENTS ONLY

Who may we thank for referring you to our office?

Name

First Last

How did you choose our office for your needs?

Please silence cell phones prior to entering the Doctor’s exam room Thank you!

General Information

Patient’s full name

First Last

If married, name of spouse

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

Cell

Home

Work

Date of Birth:

Age Now:

Sports Participation Information

Primary Sport:

Number of years played:

What level of sports did you recently participate in prior to injury?

What activity level would you like to get back to?

Professional Athlete

Competitive Athlete

Scholastic Competitive Athlete

Recreational Athlete

Following your injury, are you currently:

Unable to participate in ALL sports

Unable to participate in a MAJORITY of sports

Unable to participate in a FEW sports

Not limited in sports

Rate your current ability to perform: (10=no limitation, 1=unable to perform)

Activities of Daily Living

Strenuous work (vigorous activities)

Sports

Sedentary work (sitting activities)

Visual Health History

Reason for today’s visit

Date of last vision examination

Results

Previously Diagnosed Visual Conditions

Previous Treatments for Visual Conditions

Are you currently taking any eye drops?

Do you wear glasses?

If you have more than one pair of glasses, please describe how/ when you use them.

Do you wear contact lenses?

Yes

Full time wear

Occasional wear

Please describe your main visually demanding activities and any difficulties you encounter in doing them. Visual demands (reading, computer, etc.)

At work

At play (sports hobbies)

Sports Vision History

Any history of the following? (please check)

High blood pressure:

You

Family

Eye turn/Strabismus:

You

Family

Lazy Eye/Amblyopia:

You

Family

Diabetes:

You

Family

Thyroid Condition:

You

Family

Blindness:

You

Family

Multiple Sclerosis:

You

Family

Brain Injury:

You

Family

Stroke:

You

Family

Brain Tumor:

You

Family

Cataracts:

You

Family

Premature birth:

You

Family

Retinal disease:

You

Family

Headaches/migraines:

You

Family

Sinus problems:

You

Family

Allergies:

You

Family

Color deficiency:

You

Family

Glaucoma:

You

Family

Medical History

Most recent medical examination:

Doctor’s name

First Last

Date

Results

Medication currently taking

For what condition

Have you been diagnosed as having :

List illnesses, bad falls, head injuries, high fever, ear infections, etc. (include complications and ages)

Are you generally healthy?

Any chronic problems like asthma, hay fever, allergies?

Yes

please list

Has a neurological evaluation been performed?

Yes

By whom?

Results

Has a psychological evaluation been performed?

Yes

By whom?

Results

Have you ever received:

Occupational therapy services?

Yes

By whom? and when

Results

Physical therapy services?

Yes

By whom?

Results

Speech therapy services?

Yes

By whom?

Results

Other therapy?

Present Situation

Is there any concern that some visual dysfunction may be present?

Yes

what?

Is your visual dysfunction interfering with your ability to perform your daily functions either at home or work?

Do you experience any of the following:

Headaches

Yes

When?

Blurred vision

Yes

When?

Double vision

Yes

When?

Eyes “hurt or tired”

Yes

When?

Difficulty reading

Yes

When?

Difficulty driving

Yes

When?

Difficulty coordinating the eyes as a team

Yes

When?

Poor depth perception/ spatial judgments

Yes

Describe

Educational/ Occupational History

Level of education received

Please check all that apply to you.

Slow learner

Yes

Motion sensitive

Yes

Poor diet/ nutrition

Yes

Crave sweets

Yes

Difficult childhood

Yes

History of substance abuse

Yes

History of trouble with the law

Yes

Musical ability

Yes

Good rhythm

Yes

Light sensitive

Yes

Touch sensitive

Yes

Enjoy sports

Yes

Read for enjoyment

Yes

Hands on learner

Yes

Goals:

Satisfied with current occupational situation

Yes

please give a reason why?

Satisfied with level of education received

Yes

please give a reason why?

Other:

I authorize the release of any medical information to process my insurance claim or the referral to another doctor, school or clinic.

Signature

Date

SPORTS VISION: Patient History

Insurance Information

Financial Policy Release of Information Privacy Practices Acknowledgement

VERY IMPORTANT! NEW PATIENTS ONLY

General Information

Sports Participation Information

Visual Health History

Sports Vision History

Medical History

Present Situation

Educational/ Occupational History

Goals:

North Royalton

Beachwood

Westlake