Risk Management

Eye History Form


Name:                                                                                                                      Date:                                                                   

Thank you for choosing our office for your eyecare.  To better serve you, please answer the following questions:

  1. Do you wear glasses?                                  c   YES c   NO
  2. Do you wear contact lenses?                     c   YES c   NO
  3. Do you have problems reading?               c   YES c   NO
  4. Are you currently experiencing any eye symptoms?  Please circle all that apply:

Eye pain                        Blurred Vision                      Eyelid Crusting                     Flashes of Light                   Halos

Discharge                      Light Sensitivity                   Double Vision                       Decreased Vision                 Floaters

  1. Have you ever had an eye injury?  Please describe:                                                                                                                                                                                                                                                                                                                   
  2. Have you ever had eye surgery?  Please list type, which eye and approximate dates:



  1. Are you currently using any eye medications?  Please list name and how often used:                                                                                                                                                                                                                                                                        
  2. Are you being treated for any medical conditions?  Please circle all that apply:

Diabetes                        Heart Disease                       High Blood Pressure

Stroke                            Arthritis                                  Other:                                                                                    

  1. What medications other than above are you taking?  Please list:                                                                                                                                                                                                                                                                                            
  2. Are you allergic to any medications? Please list:                                                                                                                                                                                                                                                                                                                          
  3. Do you have any family history of eye problems?  Please circle and list family relationship:

Glaucoma                     Cataract                                Retinal Disease                    Macular Degeneration

  1. Please circle any of the following that you would like more information about:

Radial Keratotomy                     Contact Lenses                    Cataract Surgery

Diabetic Eye Disease                  Glaucoma                             Other:                                                                                    

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Six reasons OMIC is the best choice for ophthalmologists in America.

#1. Consistent return of premium.

Publicly-traded insurance companies exist to make profits for shareholders while physician-owned carriers often return profits to their policyholders. Don’t underestimate this benefit; it can add up to tens of thousands of dollars over the course of your career. OMIC has one of the most generous dividend programs for ophthalmologists and has returned more than $20 Million to our members through dividends.