www.NutriOptom.com

Nutritional Optometry Associates

 
 

Benjamin C. Lane, O.D., M.P.H., F.A.A.O. F.C.O.V.D.

Nutritional Optometrist

 

16 North Beverwyck Road, P.O. Box 131         

425 Madison Avenue at 49th Street Suite 802    

Lake Hiawatha, NJ 07034-0131

New York, NY 10017-1128

(973) 335-0111;  FAX: (973) 335-2882 or 541-1649

(212) 759-5270

“In  The  Vanguard  Of  Dietary  Research  And  Integrative  Therapy  In  The  Prevention  And  Reversal  Of  Eye  & Vision  Disorders”

 

Date:

         /         /  
Mr Ms Mrs                                                               SS#                                         
Residence                                                               Medicare#              ___ 
Town                           State               Zip            ___   Birth date                    
Height           Feet                Inches Weight                   Age      years      months
Occupation                                                Employer                                  

CONTACT INFORMATION

TELEPHONES
Residence #                          Cell #                                    Work #                                  
Email address                                          FAX#                                                 
Secondary Residence                                  City                      State              Zip            

Is this secondary residence a

 (   )Business?    (   )Vacation?    (   )Summer?    (   )Winter?    (   )Relative?    (   )Preferred as mailing address?

Person responsible for payment if other than yourself
Name                               Address                                         City                  
State                 Zip                                    Relationship                               

Nutritional Optometry Associates pledge to respect your privacy in accordance with HIPAA.  All third-party payors, laboratories, and health providers are required by law to protect your privacy.

Accounts are paid at the time our services are provided.

 ( )   DISCOVER ( )   MASTERCARD ( )   VISA ( )   DEBIT ( )

PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE:  I authorize the release of any optometric or other information necessary to process any insurance or Medicare claim and as necessary to provide appropriate treatment.  I also request payment of any benefits to myself or to the party who accepts assignment.

Signature X

  

Date

PRINCIPAL DOCTORS CONSULTED

Address

Specialty

Approx dates

Diagnoses
         
         
         
         

 

REFERRED BY

Address
 

____________________________________________

  

____________________________________________________________________

 

YOUR VISION HISTORY

1. What is your visual problem or in what way are your eyes troubling you?                                   ______________________________________________
2. Do you wear glasses now?_____________________________________________

( )No 

( )Yes 

( )Bifocals  

( )Trifocals 

( )Progressive Adds  

( )Sunglasses  

( )Occupational   

( )Low Vision

( )Constant

( )Only for Distance

( )Only for Reading

( )For Most Closework

( )Over Contact Lenses
3. How long ago were the prescriptions changed?___________________________________
4. By which Doctor's Rx?________________________________________________
5. How much time do you spend at closework at work?_________________
6. At home?_____________
7. On weekends?_________
8. Reading/working distances from the eyes in inches or feet?_________ 
9. Time spent at computer monitor?____________________________________
10. Distance from screen?_______________________________________________
11. Wearing:

( )Distance Rx

 ( )Intermediate

 ( )Near

 ( )Bifocal

 ( )Other_______________________ 

12. Hours per day wearing Contact Lenses?_____________

13. Do you have spare glasses in a current Rx?

  ( ) No  ( ) Yes

14. Does being out on a bright day make your eyes feel uncomfortable?
( )No    ( )Sometimes  ( )Somewhat

 ( )Very Uncomfortable
15. Are your eyes more uncomfortable when skies are hazy-bright?

( )No

 ( )Yes
16. Duration of glare hypersensitivity:
( )None  ( )Less than 15 minutes

( ) More than 15 minutes

 ( )Most days

 ( ) Glare

17. Discomfort experienced even when unshielded fluorescent ceiling, expanses as in supermarkets: 

( )People say I keep my home too dark—I’m  uncomfortable with normal bright residential lighting.
( )Oncoming headlights bother me more than average people.
18. HEADACHES: When?
( )None  ( )At least once/week  ( )Awaken with a headache  ( )Other
Time of day and/or associated with what activity?
__________________________________________________________________________
Where?

( )Low forehead

 ( )Inside eyes?  

 ( )Temples at sides of head? 

 ( )Back of head (occipital)? 

Or Other locations in head? 
____________________________________________
How relieved?   
__________________________________________________________________________
19. SIDE-VISION CONSTRICTION:  
 ( )No  ( ) Yes, as follows________________________________________________________
20. Do your eyes often feel dry?
( )No  ( )Yes
21. Does mucus collect in eye?
( )No  ( )Yes

 

 

EYE HEALTH HISTORY

History of parents, grandparents, siblings, and own children with possible inherited eye disorders and your own disorders:

SPECIFIC EYE DISORDERS

AFFECTED RELATIVE

DATES YOU WERE FIRST AFFECTED/TREATED
22. Cataract: Type:    Left eye  Right eye
23. Glaucoma: Type:    Left eye  Right eye
24. Macular Degeneration:    Left eye  Right eye
25. Eye Surgeries & Other:    Left eye  Right eye

HEALTH HISTORY
26. At present, any health issues ( ) No    ( ) Yes

 Medication taken

Issue used for
27.  
28.  
29.  
30. Date of last blood test                              
31. Date of last hair mineral analysis                               
32. Thyroid? ( ) No ( Yes)
33. Stomach nausea or vomiting? ( ) No  ( ) Yes
34. Injuries to head or eyes -- severe blows? ( ) No ( ) Yes 
35. Any pains in eyes? ( ) No ( ) Yes
36. Car sickness? ( ) No  ( ) Yes
37. Do you see haloes or rainbow colors around lights? ( ) No ( ) Yes 
38. Blood pressure                                                     
39. Any history of diabetes? ( ) No  ( ) Yes
40. Highest fasting blood sugar, if known                                    
41. Sinusitis? ( ) No   ( ) Yes

DENTAL HISTORY  

42. Last visit to the Dentist                  ___________ 
43. Last associated X-ray                        __________ 
44. Any impacted wisdom teeth?                            
45. Any abscessed teeth?                                         

DOMINANT
46. Hand       _ 47. Foot   ___  48. Eye     __  49. Distance    __  50. Near  ___ 

ALLERGIES
   Please describe the Degree for each type as none, slight, moderate, or severe

Type

Degree

To What

And When or How Long

51. Seasonal Respiratory

      

52. Year-round respiratory

     

53. Food allergies

      

54. To medications

      
55. Do you or did you smoke?     ( ) No   ( ) Yes

If Yes, please answer questions 56 through 58
56. What did or do you smoke  
57. How much did or do you smoke  
58. Between what years did or do you smoke

 

 

DIET

59. Are you on a special diet? Please describe it

pleas 

 

 

60.Are you taking  any vitamin, mineral, glandular, or herbal supplements? Please list them

 

61. Are you on an exercise or activity program? Please describe it

 

62. Does your diet include the eating of fish? ( ) No      ( ) Yes
63. How often do you eat tuna?                   ______________________________________________________ 
64. What other finfish or shellfish do you eat?                       ____________________________________ 
65. How often do you eat them?       _____________________________________________________________

66. Briefly, in your own words, why are you having an examination at this time? 

What do you expect or want the Doctor to help you with?

 

 

INSURANCE AND MEDICARE INFORMATION
75. Name and birth date of the person holding PRIMARY policy if other than patient.

                                                                                __________________________________  

76. Address of person if different than patient’s.

                                                                                   _________________________________ 

77. What relationship is the patient to the person holding PRIMARY policy? Please encircle

Spouse  Father  Mother Son  Daughter  Brother Sister

78. Policyholder’s I.D. #                                        __________  79. Group #:                                                               
80. Name of PRIMARY INSURANCE COMPANY

                                                                                   _________________________________ 

81. Address of PRIMARY insurance company for claim submittal

                                                                                            ____________________________ 

82.Type of policy: [encircle one]: HMO  PPO  Other ____________________________________________ 83.Co-pay Amount                ______________ 
84. Has the deductible, if any, been paid for this year? Please encircle YES  NO   UNSURE         NOT APPLICABLE
85. Name of SECONDARY INSURANCE COMPANY

                                                                                   ________________________________ 

NOTICE TO ALL PATIENTS

Bills not paid within 60 days will include a 1.6% finance charge per month. A 35% fee will be added if turned over to collection

I agree to pay deductibles & balances not covered by insurance.

Patient Signature required                                                                        Date: ___/___/___