Appointments and Insurance
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Please fill out this Patient Form. If you have any question or concerns about the form please contact
(605) 498-0427.

Vision Care Associates - Tea, SD
Dr. Jill Hart
725 Figzel Court
Suite 101
Tea, SD 57064
Phone: (605) 498-0427
Fax: (605) 498-0246

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Patient Information
Patient Information
Name: (Last, First, Middle)
Today's Date:
Address:
City:
State: Zip:
Home Phone:
Work Phone:
Birth Date: Social Security Number:
Sex: Male Female Marital Status:
Occupation: Employer:
Last Eye Exam: By Whom:
   
Party Responsible for Payment
Name: (Last, First, Middle)
Sex: Male Female Relationship to Patient:
Address:
City:
State: Zip:
Home Phone:
Work Phone:
   
Insurance Information
Medicare Number:
Medicaid Number:
Other Insurance:
Policy Number:
Payment Options:
   
Family History - Please note any family history (parent, grandparents, siblings, children, living or deceased) for the following conditions:
Disease/Condition
No
Yes
?
Relationship to You
Blindness
Cataract
Crossed Eyes
Glaucoma
Macular Degeneration
Retinal Detachment/Disease
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Thyroid Disease
Lupus
Other
   
Medical History Questionnaire
Social History
This information is kept strictly confidential. However, you may discuss this portion directly with your doctor if you prefer.
Yes, I would prefer to discuss my Social History information directly with my doctor. (check box)
Do you drive: Yes No If yes, do you have any visual difficulties when driving? Yes No
If yes, please describe:
Do you drink alcohol? Yes No If yes, type/amount/how long:
Do you use illegal drugs? Yes No If yes, type/amount/how long:
Have you ever been exposed to any of the following? no Gonorrhea Hepatitis HIV Syphilis
   
Personal Medical History
Name of Medical Doctor/Clinc:
Pharmacy:
Do you have any allergies to medications? Yes No
If yes, please explain:
List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies)
   
Ophthalmic History
None cataracts glaucoma lazy eye
drooping eyelid prominent (bulging) eyes retinal disease crossed eyes
eye infection eye injury
   
Review of Systems
Do you currently, or have you ever had any problems in the following areas?
System
No
Yes
?
CONSTITUTIONAL      
Fever, Weight/Loss/Gain
       
INTEGUMENTARY (Skin)
       
NEUROLOGICAL      
Headaches/Migraines
Seizures
       
ENDOCRINE      
Thyroid/Other Glands
       
EYES      
Loss of Vision/Side Vision
Blurred Vision
Distorted Vision/Halos
Flashes/Floaters in Vision
Double Vision

Excess Tearing/Watering

Dryness
Sandy or Gritty Feeling
Foreign Body Sensation
Mucus Discharge
Itching/Burning
Redness
Eye Pain or Soreness
Chronic Infection/Eye or Lid
Glare/Light Sensitivity
Sties or Chalazion
Tired Eyes
       
PSYCHIATRIC      
Depression
       
EARS/NOSE/MOUTH/THROAT      
Environmental Allergies/Hay Fever
Sinus Congestion/Runny Nose
Chronic Cough
       
RESPIRATORY      
Asthma
Chronic Bronchitis
Emphysema
       
VASCULAR/CARDIOVASCULAR      
Diabetes
Heart/Vascular Disease
High Blood Pressure
       
GASTROINTESTINAL      
Diarrhea
Constipation
       
GENITOURINARY      
Genitals/Kidney/Bladder
       
BONES/JOINTS/MUSCLES      
Rheumatoid Arthritis
Joint Pain
Muscle Pain
       
LYMPHATIC/HEMATOLOGIC      
Anemia
Bleeding Problems
       
ALLERGIC/IMMUNOLOGIC
 
 
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