Name

Date of Exam M/D/Y

Address

Mobile Phone

Home Phone

Email

Date of Birth M/D/Y

Gender GenderMaleFemale

Employer/Occupation:

Insurance Information

Name of Insurance Carrier

ID Number

Group Number

Policy Holder Name

Date of Birth

Ocular Concerns

What are the Symptoms?

How Severe is it? How Severe is it?MildModerateSevere

Duration of symptoms:

Treatments (current or previously tried):

Which Eye is Affected? Which Eye is Affected?LeftRightBoth

Ocular History Ocular History Dry Eye Glaucoma Macular Degeneration Surgery Trauma

Medications (please include dosage and frequency):

Medication Allergies

Smoking Status Smoking StatusSmokerNon-smoker

Alcohol Consumption Alcohol ConsumptionNoneLess than 1 drink/day1-2 drinks per day3 or more drinks/day

Review of Symptoms (check all that apply) Review of Symptoms (check all that apply) Poor Vision Eye Pain Tearing Redness Jaw Pain/Scalp Tenderness Fever/chills Weight Loss Depression Diabetes Ear Ache Cough Dry Mouth High Blood Pressure Congestion/Wheezing Diarrhea/Constipation Thyroid Abnormalities Anemia Burning with Urination/Increased Frequency/Incontinence Joint Pain/Stiffness/Srthritis Rash/Changing Moles Headache Stroke Anxiety Allergies/Hay Fever/Hives

Dry Eye Questionnaire

During the past month, how often did your eyes feel discomfort? During the past month, how often did your eyes feel discomfort? Never Rarely Sometimes Frequently Constantly

When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed? When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed? None A Little Intense Intense Very Intense Extremely Intense

During a typical day in the past month, how often did your eyes feel dry? During a typical day in the past month, how often did your eyes feel dry? Never Rarely Sometimes Frequently Constantly

When your eyes feel dry, how intense was this feeling of dryness at the end of the day, within two hours of going to bed? When your eyes feel dry, how intense was this feeling of dryness at the end of the day, within two hours of going to bed? None A Little Intense Intense Very Intense Extremely Intense

During a typical day in the past month, how often did your eyes look or feel excessively watery? During a typical day in the past month, how often did your eyes look or feel excessively watery? Never Rarely Sometimes Frequently Constantly

Macular Pigment Density Test and Retinal Photos

In order to provide you with the best eye care, our doctors recommend you complete digital retinal photographs and macular pigment testing. These tests are key in monitoring ocular health and determining best treatment options to protect your vision. Unless noted otherwise, these tests will be completed at each comprehensive eye exam. Depending upon your insurance, there may be an out-of-pocket fee of up to $40.

Please sign only to OPT OUT of this testing: E-SIGNATURE HERE

Contact Lens Contact fitting and evaluation require a separate fitting and evaluation fee which includes up to 90-days of follow up evaluation if they are necessary. All contact lens fitting fees are due at the time of exam.

I acknowledge that I am responsible for all charges for services or supplies provided by PineCone Vision Center for myself and/or any family members I am responsible for including minor children. I understand that payment is required at the time service is rendered and that if PineCone Vision Center is a provider for my insurance that they will bill eligible services to my insurance company on my behalf. Therefore, I understand that it is essential that I provide complete and accurate information regarding my insurance company. I authorize medical care and accept financial responsibility for myself and/or any family members I am responsible for including minor children. I acknowledge that I am responsible for all charges for services or supplies provided by PineCone Vision Center for myself and/or any family members I am responsible for including minor children. I understand that payment is required at the time service is rendered and that if PineCone Vision Center is a provider for my insurance that they will bill eligible services to my insurance company on my behalf. Therefore, I understand that it is essential that I provide complete and accurate information regarding my insurance company. I authorize medical care and accept financial responsibility for myself and/or any family members I am responsible for including minor children. I Agree