Sports Vision Eval Plano Step 1 of 8 12% PERSONAL INFORMATIONDr.Mr.Mrs.Ms.*MaleFemaleName* First Middle Last Birth Date* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone (Evening)*Business Phone (Day)*Last Eye Exam*Last Medical Exam*Name of Parent, Spouse or Guardian First Last Name of Medical Doctor*Doctor's Phone Number*Driver's License #*State*Social Security #*Occupation*E-mail Address* MEDICAL HISTORYList all major injuries, surgeries, and/or hospitalizations you have hadList any medications you are currently taking (including aspirin / oral contraceptives / over the counter medications and home remedies)List all medications you are allergic toAre you pregnant or nursing?*YesNoDo you wear glasses?*YesNohow old is your present pair of glasses?*Do you wear contact lenses?*YesNohow old is your present pair of lenses?*Type of contact ?*SoftExtended WearRigid Gas PermOtherAre they comfortable?*YesNoDryBlurry REVIEW OF SYSTEMSDo YOU currently, or have you ever had any problems in the following areasEYESPast Eye Injury*NOYESUNKNOWNLoss of Vision*NOYESUNKNOWNBlurred / Distorted Vision*NOYESUNKNOWNRedness*NOYESUNKNOWNItching*NOYESUNKNOWNBurning*NOYESUNKNOWNExcess Tearing / Watering*NOYESUNKNOWNDryness*NOYESUNKNOWNHalos / Glare*NOYESUNKNOWNEye Pain or Soreness*NOYESUNKNOWNSandy or Gritty Feeling*NOYESUNKNOWNForeign Body Sensation*NOYESUNKNOWNChronic Infection of lid / eye*NOYESUNKNOWNStyes or Chalazion*NOYESUNKNOWNMucous Discharge*NOYESUNKNOWNFlashes / Floaters*NOYESUNKNOWNDouble Vision*NOYESUNKNOWNTired Eyes*NOYESUNKNOWNMacular Degeneration*NOYESUNKNOWNRetinal Disease*NOYESUNKNOWNCataracts*NOYESUNKNOWNKeratoconus*NOYESUNKNOWNCorneal Transplant*NOYESUNKNOWNRetinitis Pigmentosa*NOYESUNKNOWNStrabismus (crossed / lazy eye)*NOYESUNKNOWNCONSTITUTIONALFever, Weight loss / gain*NOYESUNKNOWNINTEGUMENTARYSkin*NOYESUNKNOWNWarts / Papilloma*NOYESUNKNOWNNEUROLOGICALHeadaches*NOYESUNKNOWNMigraines*NOYESUNKNOWNSeizures*NOYESUNKNOWNENDOCRINEThyroid / Other Glands*NOYESUNKNOWNCancer*NOYESUNKNOWNIf yes, typeEARS, NOSE, MOUTH, THROATAllergies / Hay Fever*NOYESUNKNOWNSinus Congestion*NOYESUNKNOWNRunny Nose / Post- Nasal Drip*NOYESUNKNOWNChronic Cough*NOYESUNKNOWNDry Throat / Mouth*NOYESUNKNOWNRESPIRATORYAsthma*NOYESUNKNOWNChronic Bronchitis*NOYESUNKNOWNEmphysema*NOYESUNKNOWNCARDIOVASCULAR / VASCULARDiabetes*NOYESUNKNOWNHigh Cholesterol / Hyperlipidemia*NOYESUNKNOWNHigh Blood Pressure*NOYESUNKNOWNHeart / Vascular Disease*NOYESUNKNOWNHeart / Chest Pain*NOYESUNKNOWNGASTROINTESTINALDiarrhea*NOYESUNKNOWNConstipation*NOYESUNKNOWNGENITOURINARYGenitals / Kidney / Bladder*NOYESUNKNOWNBONES / JOINTS / MUSCLES Rheumatoid Arthritis*NOYESUNKNOWNMuscle Pain*NOYESUNKNOWNJoint Pain*NOYESUNKNOWNLYMPHATIC / HEMATOLOGICAnemia*NOYESUNKNOWNBleeding Problems*NOYESUNKNOWNPSYCHIATRIC*NOYESUNKNOWNOTHERIf you answered YES to any of the above or have a condition not listed, please explain and list medications SOCIAL HISTORYThis information is kept strictly confidential, however you may discuss this directly with the doctor if you prefer. Yes, I would prefer to discus my Social History directly with the doctor Do you drive?*YesNodo you have visual difficulty while driving?*YesNoplease describe*Do you use tobacco products?*YesNotype / amount / how long?*Do you drink alcohol?*YesNotype / amount / how long?*Do you use illegal drugs?*YesNoIf yes type / amount / how long?*Have you ever been exposed or infected with Syphilis Gonorrhea Hepatitis HIV Other None of the above Please list the other condition(s): FAMILY HISTORYPlease note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions: DISEASE / CONDITION Blindness*NOYESUNKNOWNRELATIONSHIPCOMMENTSCataract*NOYESUNKNOWNRELATIONSHIPCOMMENTSCrossed Eyes*NOYESUNKNOWNRELATIONSHIPCOMMENTSGlaucoma*NOYESUNKNOWNRELATIONSHIPCOMMENTSMacular Degeneration*NOYESUNKNOWNRELATIONSHIPCOMMENTSRetinal Detachment*NOYESUNKNOWNRELATIONSHIPCOMMENTSRetinal Disease*NOYESUNKNOWNRELATIONSHIPCOMMENTSArthritis*NOYESUNKNOWNRELATIONSHIPCOMMENTSDiabetes*NOYESUNKNOWNRELATIONSHIPCOMMENTSHeart Disease*NOYESUNKNOWNRELATIONSHIPCOMMENTSHigh Blood Pressure*NOYESUNKNOWNRELATIONSHIPCOMMENTSHigh Cholesterol*NOYESUNKNOWNRELATIONSHIPCOMMENTSKidney Disease*NOYESUNKNOWNRELATIONSHIPCOMMENTSLupus*NOYESUNKNOWNRELATIONSHIPCOMMENTSThyroid Disease*NOYESUNKNOWNRELATIONSHIPCOMMENTSOther INSURANCE INFORMATIONName of Insurance Provider*Phone Number*Employer*Member ID#*Group #**PrimaryDependentIf Dependant, List Name and DOB of Primary*Signature*Date* Date Format: MM slash DD slash YYYY Financial Responsibility Policy for Charles Shidlofsky, O.D., P.A. d/b/a Neuro-Vision Associates of North Texas This document is provided to you so that you will understand both your responsibility as the patient, and our responsibility as the provider in regards to your insurance coverage. We accept assignment to many insurance companies, which means, we accept a negotiated rate as a provider. As a courtesy to our patients, we do file the initial insurance claims for those companies for which we have agreed to accept assignment. All insurance information must be presented at the time of your examination. We cannot accept any changes to this information past the date of service. After that time, we can provide any information you need so that you can file the claim on your own for reimbursement. Some health plans require that we inform you in advance that they may deny payment for “services not covered”, “services not deemed by the health plan to be reasonable and customary or medically necessary”, “services not covered for this type of provider”, “diagnosis not appropriate for this type of procedure”and “procedure has been deemed to be experimental”. Charles Shidlofsky, O.D., P.A. renders only services that, in their professional judgment, are necessary to provide quality health care for you. In order for us to collect from you for our services when payment is denied by your health plan, your health plan requires that you sign the following agreement. Agreement: I have been notified by Charles Shidlofsky, O.D., P.A. that payment may be denied for the reasons above, or that have been specifically requested by me, the patient. If payment is denied, I agree to be personally and fully responsible for payment within six months. Signature*Date* Date Format: MM slash DD slash YYYY Your Health Plan Coverage Charles Shidlofsky O.D., P.A. is committed to providing you with the best possible care and helping you to receive maximum benefits under your health plan. In order to achieve these goals, we need your assistance. It is your responsibility to know if a referral is necessary for your visit Co-payments are due at the time of the visit. We are considered “Specialty Co-payments”. A valid, current insurance card must be presented at each office visit. If the service is not a covered benefit, or if your health plans tells us you are not covered, payment in full for all services rendered are due on date of service .If your insurance subsequently makes payment, any over payments will be refunded to you. Regarding Your Health Plan Your insurance is a contract between you, your employer and the insurance company. We are not party to that contract. While we may have an agreement with many of the health plans to provide services, any questions regarding coverage must be resolved by you with the insurance company. Not all services are a covered benefit in all contracts. Some health plans select certain services that they will not cover. By signing below, I acknowledge that I have read this information and understand completely. Signature*Date* Date Format: MM slash DD slash YYYY Neuro-Vision Associates of North Texas and Affiliated Organizations Authorization of Use and Disclosure of Protected Health Information Expiration Date Of Authorization: There is no expiration of this authorization. However, this authorization can be terminated at any time at the written request of the patient. Right to Terminate or Revoke Authority: You may revoke this authorization by submitting a written revocation to Neuro-Vision Associates of North Texas and affiliated organizations. You should contact the Public Information Officer to terminate this authorization. Potential for Re-Disclosure: Information that is disclosed under this authorization may be disclosed again by the person or organization to which it was sent. The privacy of this information may not be protected under the federal privacy regulation. Authorization to Contact and/or Leave Notice: Neuro-Vision Associates of North Texas and its affiliated organizations contacts patients by email or phone to remind or inform of future appointments or other medical information. This authorization allows us to contact you either by email or by leaving a message, for such purposes. Please list the contact phone number and names of persons with whom we may discuss your protected health information: Communication Preferences LocationHome Phone:*Can we contact you here?*YesNoCan we leave a text/message?*YesNoWork Phone:Can we contact you here?*YesNoCan we leave a text/message?*YesNoMobile Phone:Can we contact you here?*YesNoCan we leave a text/message?*YesNoEmail address: Can we contact you here?*YesNoCan we leave a text/message?*YesNo Please list up to two people other than your insurance company or healthcare provider with whom we can talk to about your healthcare information: Name* First Last Relationship*Phone number*Email* Name* First Last Relationship*Phone number*Email* Signature : Signature of Patient*Name of Patient* First Last Date* Date Format: MM slash DD slash YYYY Signature of Patient Representative*Name of Patient Representative* First Last Date* Date Format: MM slash DD slash YYYY ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES The law requires that Neuro-Vision Associates of North Texas and its affiliated organizations make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that: I have read or had explained to me that Neuro-Vision Associates of North Texas and its affiliated organizations Notice of Privacy Practice and agree to continue my care with that Neuro-Vision Associates of North Texas and its affiliated organizations under said terms. I was given to opportunity to read that Neuro-Vision Associates of North Texas and its affiliated organizations Notice of Privacy Practices and declined but wish to continue my care with that Neuro-Vision Associates of North Texas and its affiliated organizations under the tenns of that NeuroVision Associates of North Texas and its affiliated organizations privacy policies. I have read or had explained to me Neuro-Vision Associates of North Texas and its affiliated organizations Notice of Privacy Practice and do not wish to continue my care with Neuro-Vision Associates of North Texas and its affiliated organizations under said terms. The Notice of Privacy Practice could not be read due to the emergent nature of the care of other reason described as * I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. Patient Signature*Date* Date Format: MM slash DD slash YYYY If you are signing as a personal representative of the patient, please indicate your relationship Representative Signature*Relationship to Patient* Sports Vision History Neuro-Vision Associates of North Texas www.neurovissionassociates.com email : dr-s@dr-s.net\ Athlete's Full Name* First Middle Last If married, name of spouse First Last Sports Participation InformationPrimary Sport*Number of years played*What level of sports did you recently participate in prior to injury?Pro-MajorsPro-MinorsThird ChoiceCollegeHigh SchoolRecreational Full-time (4-7 per week)Recreational Part-time (1-3 pe week)What activity level would you like to get back to?Professional AthleteCompetitive AthleteScholastic Competitive AthleteRecreational AthleteRate your current ability to perform: (1 0=no limitation, 1 =unable to perform)Activities of Daily LivingStrenuous work (vigorous activities)SportsSedentary work (sitting activities)Visual Health HistoryReason for today's visitDate of last vision examination Date Format: MM slash DD slash YYYY ResultsPreviously Diagnosed Visual ConditionsPrevious Treatments for Visual ConditionsAre you currently taking any eye drops?Do you wear glasses?*YesNoConstantlyOccasionallyNearFarIf you have more than one pair of glasses, please describe how/when you use them.Do you wear contact lenses?*YesNoFull time wearOccasionally wearPlease describe your main visually demanding activities and any difficulties you encounter in doing them. Visual demands (reading, computer, etc.)At workAt play (sports hobbies)Any history of the following? (please check)YouFamilyHigh blood pressureEye turn/StrabismusDiabetesPremature birthRetinal diseaseHeadaches/migrainesSinus problemsLazy Eye/AmblyopiaAllergiesColor deficiencyGlaucomaMedical History Most recent medical examination:Doctor's nameDate Date Format: MM slash DD slash YYYY ResultsMedication currently takingFor what conditionHave you been diagnosed as havingLeaming disabilitiesDevelopmen tal delaysADD or ADHDCerebral PalsySeizure DisordersAutismOther problemsList illnesses, bad falls, head injuries, high fever, ear infections, etc. (include complications and ages)Are you generally healthy?Are there any chronic problems like asthm a, hay fever, allergies?If so, please listHas a neurological evaluation been perfon ned?*YesNoBy whom?ResultsHas a psychological evaluation been perfo rmed?YesNoBy whom?ResultsHave you ever received:Occupational therapy services?*YesNoBy whom and when?ResultsPhysical therapy services?*YesNoBy whom?ResultsSpeech therapy services?*YesNoBy whom?ResultsOther therapy?Is there any concern that some visual dysfunction may be present?If so 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 followingHeadaches*YesNoWhen?Blurred vision*YesNoWhen?Double vision*YesNoWhen?Eyes "hurt or tired"*YesNoWhen?Difficulty reading*YesNoDescribeDifficulty driving*YesNoWhen?Difficulty coordinating the eyes as a team*YesNoWhen?Poor depth perception/ spatial judgments*YesNoDescribeOther visual perception problems*YesNoDescribeEyes frequently reddened*YesNoIf so, when?Frequent eye rubbing*YesNoIf so, when?Frequent blinking*YesNoIf so, when?Closing or covering one eye*YesNoIf so, when?Head close to paper when reading or writing:*YesNoTilting head when reading*YesNoTilting head when writing*YesNoPresent SituationReversing letters or words*YesNoSkip, reread or omit words*YesNoVocalizing when reading silently*YesNoReading slowly*YesNoUsing a finger as a marker*YesNoPoor reading comprehension*YesNoPoor writing or printing*YesNoAvoid near tasks*YesNoShort attention span*YesNoPoor motor coordination*YesNoDifficulty catching/hitting a ball*YesNoList any other concerns that you have cone erning your vision:HistoryLevel of education receivedPlease check all that apply to you.*YesNoSlow learnerMotion sensitivePoor diet/ nutritionCrave sweetsDifficult childhoodHistory of substance abuseHistory of trouble with the lawMusical abilityGood rhythmLight sensitiveTouch sensitiveEnjoy sportsRead for enjoymentHands on learnerGoalsSatisfied with current occupational situation*YesNoIf no, please give a reason whySatisfied with level of education received*YesNoIf no, please give a reason why I authorize the release of any medical information to process my insurance claim or the referral to another doctor, school or clinic. SignedDate Date Format: MM slash DD slash YYYY
