Sports Vision Eval Plano Step 1 of 8 12% PERSONAL INFORMATIONDr.Mr.Mrs.Ms.* Male Female Name* First Middle Last Birth Date* 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 had List any medications you are currently taking (including aspirin / oral contraceptives / over the counter medications and home remedies) List all medications you are allergic to Are you pregnant or nursing?* Yes No Do you wear glasses?* Yes No how old is your present pair of glasses?* Do you wear contact lenses?* Yes No how old is your present pair of lenses?* Type of contact ?* Soft Extended Wear Rigid Gas Perm Other Are they comfortable?* Yes No Dry Blurry REVIEW OF SYSTEMSDo YOU currently, or have you ever had any problems in the following areasEYESPast Eye Injury* NO YES UNKNOWN Loss of Vision* NO YES UNKNOWN Blurred / Distorted Vision* NO YES UNKNOWN Redness* NO YES UNKNOWN Itching* NO YES UNKNOWN Burning* NO YES UNKNOWN Excess Tearing / Watering* NO YES UNKNOWN Dryness* NO YES UNKNOWN Halos / Glare* NO YES UNKNOWN Eye Pain or Soreness* NO YES UNKNOWN Sandy or Gritty Feeling* NO YES UNKNOWN Foreign Body Sensation* NO YES UNKNOWN Chronic Infection of lid / eye* NO YES UNKNOWN Styes or Chalazion* NO YES UNKNOWN Mucous Discharge* NO YES UNKNOWN Flashes / Floaters* NO YES UNKNOWN Double Vision* NO YES UNKNOWN Tired Eyes* NO YES UNKNOWN Macular Degeneration* NO YES UNKNOWN Retinal Disease* NO YES UNKNOWN Cataracts* NO YES UNKNOWN Keratoconus* NO YES UNKNOWN Corneal Transplant* NO YES UNKNOWN Retinitis Pigmentosa* NO YES UNKNOWN Strabismus (crossed / lazy eye)* NO YES UNKNOWN CONSTITUTIONALFever, Weight loss / gain* NO YES UNKNOWN INTEGUMENTARYSkin* NO YES UNKNOWN Warts / Papilloma* NO YES UNKNOWN NEUROLOGICALHeadaches* NO YES UNKNOWN Migraines* NO YES UNKNOWN Seizures* NO YES UNKNOWN ENDOCRINEThyroid / Other Glands* NO YES UNKNOWN Cancer* NO YES UNKNOWN If yes, type EARS, NOSE, MOUTH, THROATAllergies / Hay Fever* NO YES UNKNOWN Sinus Congestion* NO YES UNKNOWN Runny Nose / Post- Nasal Drip* NO YES UNKNOWN Chronic Cough* NO YES UNKNOWN Dry Throat / Mouth* NO YES UNKNOWN RESPIRATORYAsthma* NO YES UNKNOWN Chronic Bronchitis* NO YES UNKNOWN Emphysema* NO YES UNKNOWN CARDIOVASCULAR / VASCULARDiabetes* NO YES UNKNOWN High Cholesterol / Hyperlipidemia* NO YES UNKNOWN High Blood Pressure* NO YES UNKNOWN Heart / Vascular Disease* NO YES UNKNOWN Heart / Chest Pain* NO YES UNKNOWN GASTROINTESTINALDiarrhea* NO YES UNKNOWN Constipation* NO YES UNKNOWN GENITOURINARYGenitals / Kidney / Bladder* NO YES UNKNOWN BONES / JOINTS / MUSCLES Rheumatoid Arthritis* NO YES UNKNOWN Muscle Pain* NO YES UNKNOWN Joint Pain* NO YES UNKNOWN LYMPHATIC / HEMATOLOGICAnemia* NO YES UNKNOWN Bleeding Problems* NO YES UNKNOWN PSYCHIATRIC* NO YES UNKNOWN OTHER If 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?* Yes No do you have visual difficulty while driving?* Yes No please describe* Do you use tobacco products?* Yes No type / amount / how long?* Do you drink alcohol?* Yes No type / amount / how long?* Do you use illegal drugs?* Yes No If 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* NO YES UNKNOWN RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSCataract* NO YES UNKNOWN RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSCrossed Eyes* NO YES UNKNOWN RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSGlaucoma* NO YES UNKNOWN RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSMacular Degeneration* NO YES UNKNOWN RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSRetinal Detachment* NO YES UNKNOWN RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSRetinal Disease* NO YES UNKNOWN RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSArthritis* NO YES UNKNOWN RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSDiabetes* NO YES UNKNOWN RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSHeart Disease* NO YES UNKNOWN RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSHigh Blood Pressure* NO YES UNKNOWN RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSHigh Cholesterol* NO YES UNKNOWN RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSKidney Disease* NO YES UNKNOWN RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSLupus* NO YES UNKNOWN RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSThyroid Disease* NO YES UNKNOWN RELATIONSHIP RELATIONSHIPCOMMENTS COMMENTSOther INSURANCE INFORMATIONName of Insurance Provider* Phone Number*Employer* Member ID#* Group #* * Primary Dependent If Dependant, List Name and DOB of Primary* Signature*Date* 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* 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* 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?* Yes No Can we leave a text/message?* Yes No Work Phone:Can we contact you here?* Yes No Can we leave a text/message?* Yes No Mobile Phone:Can we contact you here?* Yes No Can we leave a text/message?* Yes No Email address: Can we contact you here?* Yes No Can we leave a text/message?* Yes No 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* MM slash DD slash YYYY Signature of Patient Representative*Name of Patient Representative* First Last Date* 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* 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-Majors Pro-Minors Third Choice College High School Recreational Full-time (4-7 per week) Recreational Part-time (1-3 pe week) What activity level would you like to get back to? Professional Athlete Competitive Athlete Scholastic Competitive Athlete Recreational Athlete Rate your current ability to perform: (1 0=no limitation, 1 =unable to perform) Activities of Daily Living Strenuous work (vigorous activities) Sports Sedentary work (sitting activities) Visual Health HistoryReason for today's visitDate of last vision examination MM slash DD slash YYYY Results Previously Diagnosed Visual ConditionsPrevious Treatments for Visual ConditionsAre you currently taking any eye drops? Do you wear glasses?* Yes No Constantly Occasionally Near Far If you have more than one pair of glasses, please describe how/when you use them.Do you wear contact lenses?* Yes No Full time wear Occasionally wear Please 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 name Date MM slash DD slash YYYY ResultsMedication currently takingFor what conditionHave you been diagnosed as having Leaming disabilities Developmen tal delays ADD or ADHD Cerebral Palsy Seizure Disorders Autism Other problems List 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?* Yes No By whom? ResultsHas a psychological evaluation been perfo rmed? Yes No By whom? ResultsHave you ever received:Occupational therapy services?* Yes No By whom and when? ResultsPhysical therapy services?* Yes No By whom? ResultsSpeech therapy services?* Yes No By 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* Yes No When? Blurred vision* Yes No When? Double vision* Yes No When? Eyes "hurt or tired"* Yes No When? Difficulty reading* Yes No Describe Difficulty driving* Yes No When? Difficulty coordinating the eyes as a team* Yes No When? Poor depth perception/ spatial judgments* Yes No Describe Other visual perception problems* Yes No Describe Eyes frequently reddened* Yes No If so, when? Frequent eye rubbing* Yes No If so, when? Frequent blinking* Yes No If so, when? Closing or covering one eye* Yes No If so, when? Head close to paper when reading or writing:* Yes No Tilting head when reading* Yes No Tilting head when writing* Yes No Present SituationReversing letters or words* Yes No Skip, reread or omit words* Yes No Vocalizing when reading silently* Yes No Reading slowly* Yes No Using a finger as a marker* Yes No Poor reading comprehension* Yes No Poor writing or printing* Yes No Avoid near tasks* Yes No Short attention span* Yes No Poor motor coordination* Yes No Difficulty catching/hitting a ball* Yes No List any other concerns that you have cone erning your vision:HistoryLevel of education received Please 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* Yes No If no, please give a reason why Satisfied with level of education received* Yes No If 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 MM slash DD slash YYYY
