UFEA Welcome Form

Personal Information
The mission of Union Family Eye Associates is to contribute to a lifetime of healthy vision, providing each patient with the highest quality vision care and consequent quality of life. The visual needs and wellness of each patient will always be our first priority. Everything we do shall communicate this. The information and questions below will remain confidential, and are critical to the evaluation of your vision and health. Therefore it is very important that every question be answered in detail. Thank you.
Full Name*
First NameMiddle NameLast Name
Sex*
Birth Date*
MonthDayYear
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
E-mail*
Home Phone
Area CodePhone Number
Mobile Phone*
Area CodePhone Number
Work Phone
Area CodePhone Number
NAME/LOCATION OF PRIMARY PHYSICIAN
DATE OF LAST EXAM
NAME/LOCATION OF LAST EYE EXAM
DATE OF LAST EXAM
EMPLOYER/GRADE
OCCUPATION
SPORTS/HOBBIES
MEDICAL INSURANCE
GROUP # / POLICY #
INSURANCE HOLDER
IF DEPENDENT, POLICY HOLDER NAME
DATE OF BIRTH
VISION INSURANCE
POLICY # (IF KNOWN OR APPLICABLE)
CURRENT MEDICATION
MEDICATION ALLERGIES
USE OF TOBACCO
DRINK ALCOHOL
USE DRUGS?
IF YOU ANSWERED YES TO ANY OF THE 3 QUESTIONS ABOVE, PLEASE LIST
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MEDICAL INFORMATION
Please check boxes that may apply
CHECK ANY MEDICAL CONDITIONS THAT APPLY TO YOU
NoneVascular Disease/StrokeSkin Eczema/RashSeizuersKidney/BladderLung Disease/AsthmaPsychiatricHeadaches/MigrainesAutoimmuneDiabetesCancerHigh Blood PressureThyroid DiseaseHigh CholesterolArthritisHeart DiseaseWeight Loss/GainConcussionOther
IF OTHER, PLEASE EXPLAIN
CHECK ANY EYE CONDITIONS THAT APPLY TO YOU
NoneMacular DegenerationEyeSurgeryDry Eye/AllergiesGlaucomaTurned EyesCataractsEye InjuryOther
IF OTHER, PLEASE EXPLAIN
CHECK ANY CONDITIONS THAT ARE PRESENT IN OTHER FAMILY MEMBERS
NoneRetinal DetachmentCancerTurned/Crossed EyesHeart DiseaseLazy EyeThyroid DiseaseGlaucomaBlindnessCataractsDiabetesMacular Degeneration
WHAT IS THE MAIN REASON FOR TODAY'S APPOINTMENT
WHO MAY WE THANK YOU FOR REFERRING?
IF FRIEND, RELATIVE, WEBSITE PLEASE NAME
Many people experience a variety of symptoms after working at their computer for some period of time. If you answered yes to any of the questions above, there is a new type of eyewear lens that can eliminate the symptoms and dramatically improve your comfort level when working on a computer. These eyewear lenses result from a new vision testing technology, developed specifically for computer users, which our office has been trained and certified to use. Please make sure to discuss these issues with the doctor.
Contact Lens History and Questionanaire
I am not interested in contact lensesI have never worn contacts, but I am interested in wearing contact lenses and would like to discuss my optionsI am not satisfied with the comfort of my current contact lensesI am not satisfied with the vision of my current contact lensesI currently wear contact lenses
IF YOU WEAR CONTACT LENSES, WHICH BRAND
WHAT TYPE OF SOLUTIONS DO YOU USE?
HOW OFTEN DO YOU REPLACE YOUR CONTACT LENSES?
DO YOU SLEEP IN YOUR CONTACT LENSES
Ocular Wellness Exam
Our doctors order (a) Laser Confocal Imaging (b) Cross Sectional Scan and (c) Pigment Density Testing of Macula - as part of your comprehensive eye exam. These advanced technologies are used by the doctors to detect early signs of retinal disorders, including but not limited to: glaucoma, cancer, diabetic retinopathy, high blood pressure, macular degeneration, and retinal detachment.
By perfoming these test, the doctors will likely not dilate your eyes unless the test reveals undetected eye disease. It is particularly helpful when you return for your annual exam as it provides a permanent record of your retinal condition, and each subsequent year the images can be viewed side by side to discover subtle changes and monitor your continuing eye health. There is a $55 copay associated with this procedure.
Retinal Photography
YES, I understand the importance of having Retinal Scan, and I grant PermissionNOT SURE: I am interested, but would like more information before deciding to proceed.
Pursuant to the HIPAA Privacy Rule, I authorize Union Family Eye Associates to disclose my protected health information to the following person(s) The records authorized to be released include:
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Medical RecordsBilling RecordsMedical & Billing Records
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Personal Information

MEDICAL INFORMATION

Ocular Wellness Exam