Existing Patient Information Form Please fill out the following form. When done, hit "Submit". If you have any problems with this form, please contact Advanced EyeCare directly at (407) 333-3937 or by emailing email@example.com * INDICATES A REQUIRED FIELD *Name First Last Phone # ###-###-#### Email Height, Weight, and Blood Pressure Fill in as much as you know. If you are unsure, write "I don't know". *Complaints Why are you coming in today? Please check all that apply. Patients using medical insurances must have a medically related complaint. no complaints/routine vision check blurred distance vision blurred intermediate vision blurred near vision red eyes dry eyes itchy eyes watery eyes sensitivity to light glare/halos twitching eyelid flashes loss of vision floaters/spots headaches Specify "other" Complaints Description Please indicate when the date of the symptoms(s) started and the duration of the symptom(s). Please indicate if there are any factors that onset the symptoms (i.e. night time, caffeine intake, stress, etc.) Medical History After checking off necessary items, please list all medications you are taking for those conditions. Arthritis AIDS/HIV Cancer Diabetes (insulin) Diabetes (non-insulin) Heart Disease High Blood Pressure High Cholesterol Depression Allergies (seasonal/environmental) Migrane Headaches Thyroid Disorder Sleep Apnea Specify "other" Please list any meds you are currently taking. ex. Prozac for Depression. Claritin for Allergies. *Dilated Fundus Exam The Florida Board of Optometry has established that a comprehensive eye exam for a NEW patient includes a Dilated Fundus Exam. This procedure involves putting drops in each eye that will enlarge the pupils. Dr. Larson will then examine the internal structures of the eye to ensure proper health. The drops cause light sensitivity and blur vision for 2-4 hours. Most individuals can safely drive after this procedure. There is no additional charge for this dilation. I agree to have my eyes dilated today. I do NOT agree to have my eyes dilated today. *Digital Retinal Imaging We take patient education a step further by allowing patients to see inside their own eyes. By using the KOWA Digital Imaging System, we are able to view your retina quickly and in a noninvasive manner. And the best part is this camera captures an image in less than a second without any discomfort to the patient. By performing this test annually, it is extremely helpful when you return for subsequent exams, as it stores a permanent record of the condition of your retina for future review. This test can also be performed without dilation. Early detection of retinal disorders is critical to preventing serious progression and loss of your vision. 20% of blindness is preventable with early detection. Our fee for this test is $40.00. Medical insurance companies reimburse for this test only when there are existing eye diseases. Please perform baseline Digital Retinal Imaging today. Please do NOT perform Digital Retinal Imaging today. IMPORTANT- Please make sure all required* fields have been completed before you click the Submit button.