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Address Line 2
State / Province / Region*
Zip / Postal Code*
Date of Birth*
Social Security Number (Last 4 digits only!)
How were you referred to our office?
Please check off any current conditions you suffer from*
Do you wear glasses? *
Do you wear contact lenses? *
When, approximately, was your last eye exam?
Where did you get your last eye exam?
When, approximately, was your last physical exam?
Who is your primary care physician?
Do you drink alcohol?
Do you smoke?
Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)
Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)
Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)
Please list all hospital surgeries you have ever had:
Please list all prescription and over-the-counter medications you take and for what conditions
Please list all drug allergies you have
Please check off any conditions your suffer from
Please bring all insurance cards with you to your appointment
Insurance Company Name
Insurance Company Phone Number
State / Province / Region
ZIP / Postal Code
Insured's First Name
Insured's Last Name
Insured's Date of Birth
Patient's Relation to Insured
Do you have secondary insurance?
The BioPhotonic Scanner is a groundbreaking device that measures the antioxidant levels in your skin. This is directly linked to the disease fighting antioxidant levels in your blood.We are committed to improving your health and the best approach is to be proactive. Your general well-being and your eyes are connected. Studies have shown that certain vitamins and carotenoid antioxidants decrease the risk of macular degeneration and cataracts. Knowing your current level of antioxidant protection is the first step to making improvements. Included with this test will be a discussion about general nutrition and ways to improve your levels, if needed.
Patients 50 and older, please answer the questions under Macular Degeneration before completing the rest of the form. All other patients, skip down to the COVID-19 Questions and complete the rest of the form.
Are You At Risk?
The macula is the central area of the retina, the delicate tissue in the back of the eye.
A normal macula allows you to see fine details for activities like reading and driving.
Age-related macular degeneration (AMD) is a common condition involving the macula.
AMD is the leading cause of severe vision loss in people 50 years of age or older in the U.S.
By age 60, one in ten people have signs of AMD. At age 75, this increases to one in three.
Most people with AMD are not diagnosed until they have already suffered severe vision loss.
While there is no cure, AMD can be slowed down with changes in nutrition and lifestyle.
If you answered yes to 3 or more questions, you have a greater risk of developing AMD.
Dark adaptation—the recovery of vision when going from bright light to darkness—is relatively quick in healthy eyes, but can be incredibly slow in eyes with AMD.
We offer the AdaptDx® test to measure dark adaptation. This 5-10 minute, non-invasive test can help detect AMD 3-4 years earlier than normal methods.
This screening test is not covered by insurance and will cost you $55 if we perform it as part of your examination. The results will be reviewed by your doctor and specific strategies to reduce risk of vision loss from AMD will be discussed at your visit.
Have you been, or are you ever in an environment where you come into contact with COVID-19 cases?
Have you had any contact with someone who has a confirmed case of COVID-19 in the past 14 days?
Do you have a fever or any upper respiratory symptoms (cough, sore throat, runny nose), or have you been diagnosed with pneumonia recently?Do you have a fever or any upper respiratory symptoms (cough, sore throat, runny nose), or have you been diagnosed with pneumonia recently?
Do any of your family members or close contacts suffer from any of these symptoms?
Have you traveled outside the US in the last 14 days?
If you have any comments you would like to add, please enter them here.
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At Professional Eye Care at Westar , we provide the highest quality eye care to all our patients. Schedule your appointment today.