8089 Callaghan @ IH10 210-342-1228 Patient Registration (Please Print)!!!!!!!!!!! Date: Name: DOB: Address:!! Street!!!!!! City!! State!! Zip Home Phone: Work Phone: Cellular: Occupation: Employer: Social Security # _ E-Mail Address:!! Married Single Divorced Widowed Other: Who may we thank for your referral? If no referral, how did you hear about us? Location Phone Book Google Friend Insurance Company Other Dr. Other Is anyone else in your family a patient? Y N Who? Name of Vision Insurance Company: Policy/ID # Group # Name of Primary if other than patient: Primaryʼs DOB: Primaryʼs SSN: Primaryʼs Place of Employment: _ Medical or Secondary Insurance:
Review of Systems Allergic/Immunologic! Drug allergy! Environmental allergy Rheumatoid arthritis! Lupus Other: Cardiovascular Heart disease Hypertension Stroke Vascular disease Other: Musculoskeletal Fibromyalgia Muscular dystrophy Osteoarthritis Ankylosing spondylitis Other: Gastrointestinal Crohnʼs Colitis Ulcer Digestive Other: Neurological Multiple sclerosis Epilepsy Alzheimer's Parkinsonʼs Cerebrovascular Other: Genitourinary STD, viral herpetic, chlamydia Other: Ear, Nose, Mouth & Throat Upper Resp. Tract Infection Ear ache Runny nose Sore throat Ringing/Tinitis Other: Respiratory Smoking Status: Asthma Bronchitis Emphysema Other: Integumentary Eczema Rosacea Psoriasis Other: Please list any allergies you have. Constitutional Developmental disability Weight loss Fever Fatigue Trauma Other: Psychiatric Depression Panic disorder Schizophrenia Other: Hematologic/Lymphatic Anemia Large volume blood loss Leukemia Other: Endocrine Non-insulin dependent diabetes Insulin-dependent diabetes Thyroid dysfunction Hormonal dysfunction Other: List any operations and date below. Please list ALL medications you are currently taking.
Vision History Glaucoma Cataracts Age related macular degeneration Surgery Inflammatory disorders Blurred vision Double vision Dry or burning eyes! Redness! Stye! Itching! Light sensitivity! Excess tearing/watering eyes! Tired eyes, eye fatigue! Stringy mucus in or around the eyes! Foreign body sensation! Contact lens discomfort! Scratchy feeling of sand or grit in the eye Trouble seeing distance with correction Trouble seeing near with correction Wear contact lenses Other: Chief complaint or reason for exam? Dry Eye Questionnaire Have you ever been diagnosed with Dry Eye Disease or Ocular Surface Disease? Y N When? Have you had any of the following surgeries? Cataract:!! Y N Glaucoma:!! Y N Refractive Surgery:! Y N Do you use? Contact lenses OTC eye drops such as artificial tears RX eye drops for dry eyes (e.g., Restasis) RX eye drops for Glaucoma (e.g., Xalatan, Timolol) RX eye drops for allergy (e.g., anti-inflammatory, antihistamine) Nutritional supplements (e.g., flaxseed oil, omega-3) Are your symptoms related to the following environmental conditions? Windy conditions Places with low humidity Areas that are air conditioned/heated Are you taking any of the following medications? Last exam by eye doctor: Approximate Date: Who? Antihistamines/decongestants Antidepressant or anti-anxiety Oral corticosteroids Hormone replacement therapy or estrogen Antihypertensives (e.g., diuretic, beta-blocker) Accutane or other oral treatment for acne Have you ever had punctal occlusion? Y N To help us meet all your visual needs, please mark all leisure activities and needs that apply to you: Knitting/Sewing!! Photography!! Racquetball Night Driving!! Computer!!! Gardening Home Workshop!! Golf!!! Hunting Playing Cards!! Fishing!!! Music Skiing!!! Tennis List any other activities: I hereby authorize the payment of my vision plan or medical insurance to pay benefits for services directly to Dr. Luisa M. Thompson. I understand that I am financially responsible for any and all charges not covered by my plan or not paid by my policy. Signature:
Dr. Luisa M. Thompson Therapeutic Optometrist Optometric Glaucoma Specialist Release Form 8089 Callaghan @IH10 www.eyecaresa.com Email: aec8089@eyecaresa.com T. 210-342-1228 F. 210-342-6591 Retinal Photographic Examination Dr. Thompson is pleased to provide our patients with an advanced digital Retinal Photographic Examination (RPE) as an important part of our eye exams. The RPE is a high-resolution screening that photographs your retina, providing a wide view to look at the health of your retina. The retina is the part of the eye that captures the images you see. The RPE will document your retinal image for our charts, screen for eye diseases and improve our ability to view your internal retinal health over time at a much higher resolution than a slit lamp or ophthalmoscope. This is an excellent tool to compare from year to year to monitor any changes or new developments in your eye health. This test is extremely important if you have diabetes, high blood pressure, glaucoma, or if there is family history of any of these conditions. You can expect from this exam: An in depth view of the retinal surface (where most eye diseases first manifest) The ability to review the images with Dr. Thompson An analysis of retinal digital images for future comparisons and diagnosis A complete, efficient, easy and comfortable testing Our office includes this test as part of our annual eye exam. Unfortunately vision insurance will not pay for the RPE or any retinal image unless eye disease is present; therefore, the RPE is an out of pocket expense for patients using vision insurance. If a disease has already been diagnosed all medical plans (not vision plans) will cover it. Your vision plan does not cover this test. You can still have it at an additional cost of $35.00. Please select one of the following boxes.! I Agree to have my retinal health evaluated with the Retinal Photographic!! Examination.! I would like to discuss with the doctor before deciding.! I DO NOT wish to have the Retinal Photographic Examination. I understand that! I will still have a thorough eye examination with slit lamp observation.! Patient Signature!!!!!! Date
8089 Callaghan www.eyecaresa.com Email: aec8089@eyecaresa.com T. 210-342-1228 F. 210-342-6591 Patient Consent Form Patient Name: Date of Birth: I,, consent Dr. to the release of medical records for the above specified individual to: Your insurance company PLEASE READ CAREFULLY: I understand thai my medical records are confidential. I understand that by signing this consent form I am allowing my medical information to be released upon my insurance company s request, for the purpose of Health Care Operations (including, but not limited to, provider review functions, claims payment, and quality assessment). I also understand that I may revoke my consent by written request, at any time, with this doctor. If revoked, it is understood by all parties that all information released prior to being notified of such revocation was made with my consent. I understand that I have the right to restrict the disclosure of specific information in my medical records if I request such restriction in writing, I also understand that my request for restriction may be denied if the information restricted is required for Health Care Operations. I have read the above and foregoing consent for release of information. I do hereby acknowledge that I am familiar with and fully understand the terms and condition of the consent. I further acknowledge that I received a copy of Luisa Thompson. O.D. Notice of Privacy Practices. Patient Name: Signature: Date: