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Eye Interview
COVID-19 Treatment Consent Form
I consent to receive treatment from the eye gallery during the COVID-19 outbreak.
I understand there is much to learn about the newly emerged COVID-19 including how it spreads and transmitted.
I understand that based on what is currently known about COVID-19 the spread is thought to occur mostly from person-to-person via respiratory droplets among close contacts. I understand that close contact can occur from being within approximately 6 feet of someone with COVID-19 for a prolonged period of time or by having direct contact with infectious secretions from someone with COVID-19.
I understand that carriers of COVID-19 may not show symptoms but may still be highly contagious.
I understand that due to the unknowns of this virus, the number of other patients that have been in the practice and the nature of the procedures performed here, that I have an increased risk of contracting the virus by being in the practice and by receiving treatment in the practice.
I understand that the symptoms listed below are representative of COVID-19:
● Fever
● Dry Cough
● Shortness of Breath
● Temperature
● Persistent pain or pressure in the chest
● Bluish lips or face
I confirm that I do not display or currently have any of the symptoms that are representative of COVID-19, which are outlined above.
I confirm, to the best of my knowledge, that I have not had close contact with an individual diagnosed with COVID-19 in the past 14 days.
I have read the above COVID 19-Consent Statement
Signature:
Clear
Welcome,
This pre-examination interview is highly valued by Dr. Bulos and his staff.
Please answer every question honeslty, just as you would in person.
Your answers will be clarified during your examination.
Thank you.
Name
*
First
Last
Date of Interview
*
MM
/
DD
/
YYYY
Person completing interview:
*
Please select
Self
Parent of above
Primary Language
*
English
Other
Gender
Please select
Male
Female
Other
Race
Please select
White
American Indian or Alaska Native
Asian
Black of African American
Native Hawaiian or Other Pacific Islander
Other Race
Ethnicity
Non Hispanic or Latino
Hispanic or Latino
Reason for your visit?
*
Please select
Annual routine eye examination.
Specific Eye Condition
What is your occupation?
This information is useful in knowing how you use your eyes at work.
OCCUPATION:
EYE CONCERNS:
Are you having any of the following eye concerns?
*
Redness
Burning
Itching
Tearing
Discharge
Droopy Eye Lids
NO EYE CONCERNS
VISION CONCERNS:
Are you having the following vision concerns?
*
Blurred Vision
Eyestrain
Severe Sensitivity to Lights
Persitent Headache
Poor Night Vision
Bothersome Night Glare
Double Vision
Droopy Eye Lids/ Low Lying Lids
NO VISION CONCERNS
Which image best represents your own eyelids?
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2
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Please type any additional eye or vision concerns.
Please tell us about your current corrective lenses.
What corrective lenses are you mainly using for FAR/DISTANCE vision activities?
*
Please Select
None
Glasses
Contact Lenses
Describe the quality of your FAR/Distance vision activities.
*
Please Select
Acceptable
May Need Improvement
Blurry
What corrective lenses are you mainly using for NEAR/READING vision activities?
*
Please Select
None
Glasses
Contact Lenses
Contact Lenses and Readers
Describe the quality of your NEAR vision activities.
*
Please Select
Acceptable
May Need Improvement
Blurry
What corrective lenses are you mainly using for COMPUTER vision activities?
*
Please Select
None
Glasses
Contact Lenses
Describe the quality of your COMPUTER vision activities.
*
Please Select
Acceptable
May Need Improvement
Blurry
Please type any additional concerns with your current corrective lenses.
COMPUTER DEMANDS
Do you have any of the following computer demands on your vision?
*
Computer Use for Extended Periods
Unusual Ergonomic Demands
Use of Laptop
Use of Multiple Desktop Monitors
NO COMPUTER DEMANDS
Hours of computer Use per day.
Please type any additional computer demands.
VISION PERFORMANCE
Do you have any of these vision performance problems?
*
Poor reading skills or reading performance.
Inconsistent sports vision performance.
Slowness when shifting focus.
Difficulty with 3-D images, movies or TV.
NO VISION PERFORMANCE PROBLEMS
OUTDOOR DEMANDS
Describe any special outdoor demands.
*
Extended night driving.
Outdoor in direct UV exposure.
Irritated contact lenses when outdoors.
NO SPECIAL OUTDOOR DEMANDS
Please type any additional outdoor demands.
EYEGLASS DESIRES & PURCHASING PLANS
Do you have any of the following desires for your eyeglasses?
Replace uncomfortable, broken, or lost eyeglasses.
Need extra eyeglasses for special activities.
Interest in specific fashion or brands.
Would like thinner, lighter lenses.
Reduction of glare.
Other
INTERESTS
Do you plan to purchase any of the following?
New eyeglasses
Prescription sunglassses
Computer eyeglasses
Sport eyeglasses
New supply of contact lenses
no plans, exam only
Other
Are you interested in any of the following?
New contact lens fitting.
New technology or more comfortable contact lenses.
One-day contact lenses.
Contact lenses of a different replacement schedule.
Laser vision correction.
Other
CONTACT LENS HISTORY (IF APPLICABLE)
If you wear contact lenses please complete this section.
If not.. go to next page.
Type of contact lens:
Please Select
Soft
RGP
Hybird
Multifocal
Brand of contact lens:
Please Select
Acuvue
B&L
Cooper Vision
Ciba
Other
I don't know
Consider you typical day. Which ones sound the most like what you experience. You may select more than one.
Image
I frequently use digital devices throughout the day.
Yes
My eyes feel dry and uncomfortable by the end of the day.
Yes
Notice that my up-close vision has become worse.
Yes
I have an active lifestyle, and Idon't like carrying contact solution and cases with me all the time.
Yes
Replacement schedule :
Please Select
1 day as prescribed.
2 week as prescribed.
1 month as prescribd.
Every 3 months as prescribed.
Every 6 months as prescribed.
Yearly
Whenever they get uncomfortable or irritate my eyes.
Please type any other additional concerns about your contact lenses.
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