Strabismus/Amblyopia (Wandering/Crossed or Lazy Eyes)
Head Injury/Stroke/Other Neurological Insult? (Use the back of the final page if you need more space to describe)
Review of Systems
Please mark each box. Indicate Yes or No for any current diagnoses or symptoms for the following.
Personal Medical History
Family Medical History
Check each one Yes or No to indicate of any member of your family has had these diseases. Family history includes
your parents, grandparents, siblings, and your children.
Please answer the following questions (for young children you can select N/A):
Visual Signs/Symptoms Checklist
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 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.
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.
I have read and accept this policy,
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
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
Our office and electronic systems are secure from unauthorized access and our employees are trained to make certain that the
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.
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
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.
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)
2 Eye strain, soreness, pain, or discomfort
3 Eyes get tired and generally become tired
4 Double vision, shadowing of letters, words move, jump, swim, appear to
float on the page
5 Blurry Vision even though glasses are on or have been told glasses are
6 Loss of place, skipping words and/or lines while reading, or have to
reread the same line of words
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)
8 Academic Concerns (Poor Interest in reading and school, poor reading
comprehension, poor grades, homework takes longer than it should,
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)
11 Poor attention, focus, concentration, hyperactivity?
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)
13 Behavior problems, poor self-esteem/confidence, easily frustrated,
14 Eye wanders or crosses?
15 Other - please describe: (difficulty with multitasking, auditory
processing difficulties, etc.
Closed for Lunch everyday from 1-2 pm