Adult HX Forms Survey | Eye Therapy Vision Rehabilitation Center

Head Injury/Stroke/Other Neurological Insult? (Use the back of the final page if you need more space to describe)

Please describe including date of injury and accompanying signs and symptoms:

Have you had head imaging?

YesNo

Are you under the care of a physician for the above event?

Yes-CurrentlyYes-In the PastNever

Were any of the signs or symptoms mentioned above present before this event?

YesNo

Is there any other information you feel would be helpful/important in your treatment?

Patient’s Name:

DOB

Date

Social History

Please answer the following questions (for young children you can select N/A):

Do you currently or have you in the past used tobacco products?

YesNoN/A

Please describe your alcohol consumption (how many days per week you drink and how many drinks you have in an average week)?(for young children you can write N/A):

If you use them, please describe your use of Recreational/Street drugs (How long you have taken them, what type, the amount taken, and the frequency of taking them)?

Female: Are you pregnant?

YesNoN/A

Release of Information

IT IS OFTEN BENEFICIAL TO US TO DISCUSS EXAMINATION RESULTS AND TO EXCHANGE INFORMATION WITH OTHER HEALTH CARE PROFESSIONALS INVOLVED IN YOUR CARE. PLEASE SIGN BELOW TO AUTHORIZE THIS EXCHANGE OF INFORMATION.

I'm the Parent of and undersigned give Eye Therapy, permission to release any Protected Health Care Information regarding my medical records, including diagnosis to other health care professionals, specifically, but not limited to those listed below, when it is necessary for the treatment of my visual condition.

Primary Care Physician/Clinic

Primary Eye Doctor/Clinic

Other Physician/Clinic

Spouse/Significant Other

Signatures:

Name of the signer below

Name of the Child

Parent’s or Guardian’s Signature (Initial)

Date

Expires on:

End of TreatmentSpecific Date

INSURANCE – ONLY AN ESTIMATE:

Eye Therapy is willing to provide you with an ESTIMATE of what your insurance will or will not cover. However, we cannot and do not guarantee that the ESTIMATE we provide is correct. When we as the provider or you call in to get the ESTIMATE it is given with the statement “this is not a guarantee of payment”. Please understand that while we will assist you in understanding your benefits, we have no influence over your coverage. You are ultimately responsible for all fees and charges on your account.

I understand that payment in full is due at time of service unless other arrangements have been made.

authorize and request my insurance company to pay directly to the doctor insurance benefits otherwise payable to me. I also give permission for Eye Therapy to release any Medical Records requested by my insurance company for claim processing. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf.

Thank you,

I have read and accept this policy,

Patient name

Responsible party name

Signature of Parent/Guardian (Initial)

Date

STATEMENT OF PRIVACY PRACTICES

Our office is dedicated to protecting the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principal concept of our practice. We may, from time to time, amend your privacy policies and practices but will always inform you of any changes that might affect your rights.

Protecting Your Personal Healthcare Information
We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Washington. This includes issues relating to your treatment, payment, and our vision and medical care operations. Your personal health information will never be otherwise given to anyone, even family members, without your written consent. You, of course, may give written authorization for us to disclose your information to anyone that you choose, for any purpose.

Our office and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients so you can be confident that your protected health information will never be improperly disclosed or released.

Collecting Protected Health Information
We will only request personal information needed to provide our standard of quality vision and medical care, implement payment activities, conduct normal optometric practice operations, and comply with the law. This may include your name, address, telephone number(s), social security number, employment data, medical history, and health records. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law

Disclosure of Protected Health InformationAs stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and government officials under certain circumstances. We will not use your information for third party marketing purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your appointments, including voice mail messages, answering machines, postcards, and email.

Patient Rights
You have the right to request copies of your healthcare information and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately

We thank you for being a patient at our office. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information.

HIPAA Privacy Practice Acknowledgment

I have received or was offered and declined a notice of privacy practices.

Patient name

Signature of Parent/Guardian (Initial)

Date

Name

DOB

10-POINT SCALED SYMPTOM SURVEY

On a scale from 0-10 (10 being most severe) how severe are the following symptoms while doing visual tasks?

1 Headaches (In general including frequency and severity)

Score :

Comments :

2 Eye strain, soreness, pain, or discomfort

Score :

Comments :

3 Eyes get tired and generally become tired

Score :

Comments :

4 Double vision, shadowing of letters, words move, jump, swim, appear to float on the page

Score :

Comments :

5 Blurry Vision even though glasses are on or have been told glasses are unnecessary

Score :

Comments :

6 Loss of place, skipping words and/or lines while reading, or have to reread the same line of words

Score :

Comments :

7 Motor Coordination/Difficulties with Depth perception (accident prone, poor hand-eye coordination, avoid or have poor performance in sports, frequently knock things over, trip, fall, or run into things, poor rhythm/timing)

Score :

Comments :

8 Academic Concerns (Poor Interest in reading and school, poor reading comprehension, poor grades, homework takes longer than it should, poor handwriting)

Score :

Comments :

9 Visual Perceptual Difficulties (Letter reversals, confusion with words, letters, numbers, symbols, get lost in details, fatigues or becomes confused with too much info on page, confused with different fonts, poor visual recall)

Score :

Comments :

10 Balance/Dizziness/Vertigo/Disorientation/Nausea?

Score :

Comments :

11 Poor attention, focus, concentration, hyperactivity?

Score :

Comments :

12 Brain fog, sensory overstimulation, motor overload (Unable to think clearly with too much stimulus, overwhelmed with too much light, sound, busy visual environments/patterns, unable to sit still or reflexive movements due to overstimulation)

Score :

Comments :

13 Behavior problems, poor self-esteem/confidence, easily frustrated, anxiety, depression

Score :

Comments :

14 Eye wanders or crosses?

Score :

Comments :

15 Other - please describe: (difficulty with multitasking, auditory processing difficulties, etc.

Score :

Comments :

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