kimdoanmd.com - ADVANCED OPTICAL NEW PATIENT

Welcome to Advanced Optical and thank you for choosing us for your eye health and vision care needs. In order to prepare for your evaluation and for us to provide you with the best care for your individual needs, please review and complete the attached forms.
GENERAL INFORMATION
Name*

First NameMiddle NameLast Name
Sex*

MaleFemale
Age*
Social Security #*
Marital Status*

SingleMarriedDivorcedWidowed
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Mobile Phone*

Area CodePhone Number
Email*
example@example.com
Emergency Contact
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship*
Date of Last Eye Exam*

MonthDayYear
Date
Name of Previous Eye Doctor

First NameLast Name
Vision Insurance Carrier
Policy Number
How did you find about our office?*

DoctorSocial MediaFriend
Acknowledgement of Receipt of Notice of Privacy Practices

I understand that I have certain rights to privacy regarding disclosure of my health information. I understand that this information may be used to direct treatment, payment, or health care operations. Unless I decline, relevant information may be shared with family involved in my eye care. I authorize the release of any medical information necessary to provide the most beneficial and complete visual examination. I understand that I may request, in writing, to restrict how my information is shared. By signing below, I acknowledge the above and that I have reviewed or been given the opportunity to review Advanced Optical’s Notice of Privacy Practices (available on our website at www.advancedopticaleyes.com), which further details the uses and disclosures of my health information.
Signature*

Clear
Date*

MonthDayYear
Date
Financial Agreement

I understand that I am financially responsible for all charges and it is my responsibility to pay balances not paid by insurance. I understand that most insurances do not pay for refractions (to obtain an eyeglass prescription). If I have a refraction, I am responsible for the refraction fee of $75. Payment is due at the time services are rendered.

We, at Advanced Optical, sincerely appreciate your business and we strive to offer you the very best in products and services. Making high quality eyewear takes time and expertise. These are custom items made specifically for you in order to meet your needs. Hence these items cannot be reused or returned to the manufacturer. Therefore, there are no returns or refunds on any prescription eyewear. Rest assured we will make every effort to correct any issue you may have and work with manufacturers directly on your behalf. It is of the utmost importance to us that you are seeing well and you love the way you look and feel with your new glasses and/or contacts.
Signature*

Clear
Date*

MonthDayYear
Date
MEDICAL HISTORY QUESTIONNAIRE
Please check all that apply*

Poor visionLoss of visionEye painGlaucomaDiabetic retinopathyCataractsDrynessExcess tearingRednessFluctuating visionDistorted visionSandy/gritty feelingItchingBurningDrooping eyelidsSorenessGlare/light sensitivity halosOther
Please explain any boxes you have checked: *
Do you currently have a problem with any of these systems? Please check all that apply: *

General/Constitutional (fever, heat stroke, weight loss or gain, unusually tired, etc.)Cardiovascular (high BP, racing pulse, etc.)Gastrointestinal (stomach upset, diarrhea, constipation, hernia, ulcers, etc.)Musculoskeletal (joint pain, stiffness, swelling, cramps, arthritis, etc.)Neurological (numbness, headache, seizures, paralysis, etc.)Endocrine (diabetes, hypothyroid, etc.)Allergic/Immunologic (sneezing, swelling, redness, itching, hives, lupus, etc.)Ears/Nose/Throat (hard of hearing, stuffy nose, earache, cough, dry mouth, etc.)Respiratory (congestion, wheezing, shortness of breath, etc.)Genital, Kidney, Bladder (painful/frequent urination, impotence, yellow jaundice, etc.)Skin (pimples, warts, growths, rash, etc.)Psychiatric (anxiety, depression, insomnia, etc.)Blood/Lymph (bleeding, cholesterolemia, anemia, etc.)Other
Please explain any boxes you have checked: *
Any allergic reactions to medications or other substances (latex, etc.)?*

YesNo
Please list:*
General Physician
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Do you smoke?*

YesNo
How often?*
Do you drink alcohol?*

YesNo
How often?*
Do you take medications?*

YesNo
Please list names and how often?*
Do you use other substances?*

YesNo
Do you have family history of any of the following?*

DiabetesGlaucomaHigh blood pressureMacular degenerationRetinal detachmentCataractsBlindnessHeart diseaseStrokeCancerThyroid diseaseOther heritable diseases
Please explain any boxes you have checked:*
VISION & LIFESTYLE QUESTIONNAIRE
Please complete this questionnaire so we can better understand your daily vision needs.
What is your occupation?*
How many hours a day do you spend per activity?
Reading*
Computer*
Smart Phone*
Tablet*
Digital Equipment*
Do you drive?*

YesNo
Any visual difficulties?*
Do your eyes feel tired or strained at the end of the work day? *

YesNo
Do you experience sensitivity to light?*

YesNo
Does glare bother you?*

YesNo
Do you regularly participate in outdoor exercise?*

YesNo
Please describe*
Do you regularly participate in any contact sports?*

YesNo
Please describe*
Do you wear sunglasses with UV protection? *

YesNo
Does driving at night bother you?*

YesNo
Eyewear Needs*

Daily WearSafetyDrivingReadingNon-prescription SunglassesFashion FramesPrescription SunglassesColored Contact LensesSport
Occupational Needs*

Computer GamesProtectiveAbsorptionSafety
What is important to you?*

ComfortUpdating Your LookThin LensBackup PairOptimized VisionCurrent Lens TechnologyGlare ReductionMelanoma Prevention
Please describe any additional eyewear needs you would like to address: *
Should be Empty:

GENERAL INFORMATION

MEDICAL HISTORY QUESTIONNAIRE

VISION & LIFESTYLE QUESTIONNAIRE