Home Form During Covid-19
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2020-07-09T07:16:50-06:00
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Thank you for taking the time to fill out our patient intake form. The Brinton Vision Ocular Analysis is a process focused on YOU, and this intake form represents the first step in that process. As we get to know each other better you will find that our Brinton Vision team is caring, detailed, and thorough as we work alongside you to help you meet your vision goals. Because of this, our form asks you to answer a number of very specific questions about how you use your eyes – we appreciate your providing a complete response to each question. Our patients tell us that this form takes about twenty (20) minutes to complete. Thank you in advance!
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I understand
About you
Please provide us with a photo so that our staff can know who to expect (optional).
Max. file size: 50 MB.
First and other given names (as on government issued ID)
*
Family name/surname (as on government issued ID)
*
Preferred name or nickname
Date of Birth (as on government issued ID)
MM slash DD slash YYYY
Age
*
Please enter a number from
15
to
105
.
Occupation and employer
*
Emergency contact information
Emergency contact
*
Relationship
*
Mobile phone number
*
A great deal of information about your overall wellness and ocular health is shared during your Brinton Vision Ocular Analysis. Our patients often mention that they appreciated having a friend or family member participate to provide them with a second set of eyes and ears.
During the Covid-19 pandemic, patients are welcome to bring one guest with them to the office for their initial consultation. In order to limit potential exposure in our office, only patients are allowed for surgery and post operative appointments.
Name and relationship of expected guest
How did you hear about us?
These questions help us better share the benefits of visual freedom and lens-free eyesight with people in our St. Louis community – people just like you.
Which of the following do you use?
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Instagram
Facebook
Yelp
Reddit
NextDoor
None of the above
Where have you heard about Brinton Vision? Choose all that apply.
*
Word of mouth referral
My eye doctor recommended Brinton Vision
Internet search
Internet ad
Social media
Radio
Billboard
Magazine
Other
Who can we thank for recommending us?
Other
If your eye doctor referred you to Brinton Vision, please provide the doctor's name and practice information here.
*
For how many years have you seen this doctor for clinic exams?
I have not had an eye exam with this doctor
1-2 years
3-4 years
5-9 years
10-14 years
15-20 years
20+ years
Who in the doctor’s office told you about Brinton Vision?
Doctor
Receptionist
Technician
Other
Could you tell us their name so we can thank them?
Which search engine did you use?
*
Google
Bing
Other
Where did you find us in your Google search?
*
Google ad (first result on page)
Google ratings / reviews (map area)
Organic results (below the map)
Not sure
Do you recall what phrase you searched in Google? (optional)
Which one of our patients did you hear talking about us on the radio?
*
Cindy Collins (103.5 KLOU)
Bernie Miklasz (101.1 ESPN)
Dusty (93.7 the Bull)
Rizzuto (105.7 the Point)
Lux (105.7 the Point)
Mark Cox (97.1 FM NewsTalk)
Mike Ferguson (101.9 NewsTalk STL)
Bud and Broadway (92.3 New Country)
Kristie (Z107/Kristie On Air)
Frank O. Pinion (590 the Fan / AM in the PM)
Paul Cook (Y98)
Mark Klose (KSHE 94.7)
Other Brinton Vision patient on radio
St. Louis public radio (NPR 90.7)
Which magazine article did you see?
*
Full Page
Best Doctors
Don't remember
On which of these social media properties did you hear about Brinton Vision?
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Facebook
Yelp
Instagram
Twitter
Reddit
Other
Visual aids for poor eyesight
Which best describes the prescription lenses you use?
*
Prescription glasses only
Mostly prescription glasses, occasional contacts
Mostly contacts, occasional prescription glasses
Contacts only
Do not wear prescription glasses or contacts
How old were you when you first put on prescription glasses?
*
Please enter a number from
1
to
105
.
Have you ever worn contact lenses in the past? Whether yes or no, please explain.
*
We would like to get a sense of how dependent you are on glasses/contacts to see. Assuming 17 waking hours in a day, for how many of these waking hours do you depend completely on prescription glasses/contacts to see?
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1 hour or less per day
2 hours per day
3 hours per day
4 hours per day
5 hours per day
6 hours per day
7 hours per day
8 hours per day
9 hours per day
10 hours per day
11 hours per day
12 hours per day
13 hours per day
14 hours per day
15 hours per day
16 hours per day
17 hours per day
How do you read print up close / within arm's reach?
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Use readers
Use readers, but only when wearing contacts
Take off my glasses to read
None of the above - no issues with reading
What power of readers do you use?
At what age did you start using readers or taking off glasses to read?
*
We would like to get a sense of how dependent you are on reading glasses to see. Assume 17 waking hours/day. In your average day, for how many waking hours do you depend on reading glasses for near/reading vision?
*
1 hour or less per day
2 hours per day
3 hours per day
4 hours per day
5 hours per day
6 hours per day
7 hours per day
8 hours per day
9 hours per day
10 hours per day
11 hours per day
12 hours per day
13 hours per day
14 hours per day
15 hours per day
16 hours per day
17 hours per day
On May 22, 2020, the American Academy of Ophthalmology recommended that contact lens wearers switch to preferentially wear glasses during the present pandemic. Reference https://www.aao.org/eye-health/tips-prevention/coronavirus-covid19-eye-infection-pinkeye.
*
I understand
How old were you when you first used contact lenses?
*
Please enter a number from
1
to
105
.
Optional comments on why you prefer one lens type over another. Have you used glasses, contacts, or readers at different times in your life or for different circumstances?
It's not fair that some people have to go through life with a prescription – our procedures level the playing field.
About your glasses
How old is your glasses prescription?
*
a few months old
about a year old
less than 3 years old
more than 3 years old
Describe positives and negatives of your glasses-aided vision
*
Can you wear or bring these glasses to your BVOA appointment?
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Yes
No
--> It is helpful in the treatment planning process to have your current glasses and test you in them.
If you have numbers from a glasses prescription, please enter them here. Include add power for bifocals, progressive bifocals, or trifocals if you wear these.
Presbyopia occurs in your forties or fifties when you lose the ability to read up close. While our procedures are designed to restore everyday reading vision – so you can see your watch, dashboard, cell phone, and restaurant menu again – they are are not designed to replace magnification for professional level near vision. Some patients may still use a pair of readers for magnification with some near vision tasks, particularly in a professional setting or when fine print or dim lighting are involved. Talk to your Brinton Vision doctor about your near vision needs, and remember that surgical corrections over age 40 involve give and take or trade-offs, even if your procedure allows you to see everything you need to.
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I understand
You just left your house for work and discovered that you forgot your reading glasses.
*
I would have to turn around and return home to get them to make it through a work day
I would be just fine without them
You just boarded a flight for a weeklong vacation and discovered that you forgot to pack reading glasses.
*
I would have to go to the store and buy readers to make it through vacation
I would be just fine without them
About your contact lenses
How old is your contacts prescription?
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a few months old
less than a year old
less than 18 months old
more than 18 months old
Do you wear special contacts to help with your near vision?
Multifocal contacts
Monovision contacts
None of the above
With monovision contacts, which eye is set for distance and which is set for near? When does monovision work well or not work well for you?
Describe positives and negatives of your contacts-aided vision
*
Can you bring your contact lens boxes or unopened lenses to your BVOA appointment?
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Yes
No
--> It is helpful in the treatment planning process to have your current contact lens prescription information.
Picture of your contact lens foil, side of box, or eye prescription showing numbers
Max. file size: 50 MB.
You may also enter your contact lens prescription numbers here.
Contact lens habits, risks, and complications
What type of contact lenses do you wear?
*
Soft contacts
Toric soft contacts (for astigmatism)
Hard, RGP, CRT, hybrid, or scleral
For how many days will you be out of your contacts before your Brinton Vision Ocular Analysis?
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1 day or less
2 days
3 days
4 days
5 days
6 days
>7 days
Where possible, we recommend being out of contact lenses for 3 days; being out for 7 or more days is ideal.
Which of the following risky contact lens habits have you practiced?
*
Sleep in contacts
Shower with contacts
Swim with contacts
Wear longer than prescribed
Do not wash hands when removing or replacing
Do not have any of these bad contact lens habits
Which of the following complications have you experienced from contact lens wear?
*
Droopy eyelids
Eye redness or tired-looking eyes
Scar tissue
Irritation
Dryness
Allergies
Eye fatigue
Computer eye strain
Blurriness or loss of vision
Contact lens-related eye infection
I have not experienced any of these
Have you previously had LASIK or any other vision correction procedure?
*
Yes
No
Past eye procedure details
Which procedure did you have?
*
LASIK
PRK
Radial keratotomy / RK
• MYOPIA. In 95% of cases LASIK/PRK is performed for myopia (nearsightedness). Prior to LASIK/PRK you could probably read up close just fine but could not see clearly in the distance without glasses. You may have noticed that when you put on your previous glasses objects looked smaller / minified and your eyes may have looked smaller in the mirror when looking through your glasses. Your far distance vision should have improved after laser eye surgery for MYOPIA.
• HYPEROPIA. In 5% of cases LASIK/PRK is performed for farsightedness (hyperopia). Prior to LASIK/PRK you could probably see okay in the distance (though if you had very strong hyperopia even this may have been difficult). Your near vision was probably not good, or if you could see to read up close it strained your eyes. You may have noticed that when you put on your previous glasses objects looked bigger / more magnified and your eyes may have looked bigger in the mirror when looking through your glasses. Your near vision in particular should have improved after laser eye surgery for HYPEROPIA.
Did you have LASIK/PRK to correct myopia or hyperopia?
*
Myopia
Hyperopia
Don't know
Procedure date, location, and name of surgeon
*
MM slash DD slash YYYY
Were you completely satisfied after your procedure?
*
Yes
No
Are you looking to have laser enhancement of your vision or other correction?
*
Yes
No
What are your current vision challenges?
*
My far/distance vision is blurry (e.g. difficulty reading street signs)
My close/reading vision is blurry (e.g. difficulty reading a restaurant menu)
Everything is blurry or not sure
Comments
Patients who have had a previous LASIK, PRK, or RK procedure may qualify for either a laser enhancement procedure or refractive lens exchange (RLE) procedure. To learn more,
click here.
My vision challenges
For patients age 15-39, which vision problem do you have?
*
MYOPIA (nearsightedness). Up close I can see my cell phone and other near items. Street signs and far away print are blurry. My prescription starts with a minus (-) sign.
HYPEROPIA (farsightedness). I can see far away in the distance okay without my glasses, but I sometimes get headaches or eyestrain, especially with up close reading. My prescription starts with a plus (+) sign.
Everything is blurry or not sure
For patients age 40 and up, which vision problem do you have?
*
MYOPIA (nearsightedness). I've worn glasses or contacts since I was young. I can see up close but in the far distance my natural eyesight is poor. My prescription starts with a (-) sign.
HYPEROPIA (farsightedness). My vision was excellent until I started to lose reading vision near my 40's. I can't read a restaurant menu anymore, have started to wear readers, and may even need distance glasses or bifocals/progressives. My prescription starts with a (+) sign.
Everything is blurry or not sure
Near reading and computer work
What would be your ideal distance in inches for using your cell phone? A precise measurement involves using a tailor/sewing tape measure from the bridge of your nose to the center of your phone. You may also give your best estimate.
*
Please enter a number from
8
to
24
.
Do you use a computer on a daily basis?
*
Yes
No
For how many days in an average week?
*
Please enter a number from
1
to
7
.
For how many hours in an average day?
*
Please enter a number from
0.5
to
18
.
Do you use a laptop, desktop, or both?
*
Laptop
Desktop
Both
How many computer monitors do you use at a time?
*
1
2
3 or more
Approximately how far away is your monitor?
*
Close-in (12"-16")
Intermediate (18"-20")
Farther out (24" or more)
Don't know
(Optional) Have someone take a picture of you at your office or home computer workspace showing where your monitors and papers are positioned relative to where you sit. You can return to this later if needed.
Max. file size: 50 MB.
(Optional) Have someone take a picture of you at your desk or other workspace showing where you position papers or other items you work with up close. You can return to this later if needed.
Max. file size: 50 MB.
Past eye history
Select all vision conditions that apply
*
Double vision, eye crossing, or prism in glasses
Chronic eye rubbing
Chronic dry eye
Eye surgery, other than LASIK
Halos, glare, or starbursts around lights
Keratoconus (self, parent, or sibling)
Glaucoma (self, parent, or sibling)
Retinal tear or detachment (self, parent, or sibling)
Herpes eye infection
Other eye condition
I have never had an eye problem or treatment
Please explain
Keratoconus
How is/was the keratoconus treated?
*
glasses or soft contacts
hard or specialty contacts
corneal collagen crosslinking (CXL)
cornea transplant
don't know
Glaucoma
How is/was the glaucoma treated?
*
eye drops
lasers
glaucoma surgery
I don't know
Dry eye
What dry eye treatments have you used? Which have been successful?
*
General medical health
Select all health conditions that apply
*
I do not have any medical conditions
Heart condition
Diabetes
High blood pressure
Anxiety or depression
Obsessive compulsive disorder (OCD)
Pregnant, trying to become pregnant, or nursing
Autoimmune, collagen vascular, or immunodeficiency disease
Rosacea
Nickel / jewelry allergy
Pacemaker or ICD
Other health concern
Please explain any conditions noted above. Is your condition well managed and stable?
If you are pregnant, please let us know and we will reschedule your Brinton Vision Ocular Analysis for one month after your child's due date. Women planning to have LASIK or vision correction surgery should not attempt to become pregnant until they have concluded their postoperative medicated eye drops following their vision correction procedure. Nursing mothers should "pump and dump" while taking their prescribed eye procedure medications. Most procedures require one week of medicated eye drops.
*
I understand
Would you be able to obtain written clearance from your primary care medical provider stating that your condition is well-managed and stable for six months prior to your eye procedure?
*
yes
no
not sure
Do you have type I or type II diabetes? Please share last hemoglobin A1c value and date of test.
*
Select an autoimmune condition
*
Rheumatoid arthritis
Inflammatory bowel disease (ulcerative colitis or Chrons)
Sjogrens syndrome
Lupus
Dermatomyositis
Sicca syndrome
Psoriatic arthritis
HIV positive
Granulomatosis with polyangiitis
Scleroderma, systemic sclerosis, CREST syndrome
Other
Other autoimmune condition
Medications and supplements
Have you ever taken the acne medication Accutane/isotretinoin or an alpha-blocker used to treat urinary symptoms or enlarged prostate such as Flomax, Hytrin, Cardura, or Uroxatra?
*
Yes to Accutane
Yes to Flomax or equivalent
No
Do you use any of the following that can cause dry eye?
*
Blood pressure pill
Oral contraceptives
Hormone replacement therapy
Allergy pill (Allegra, Claritin, Zyrtec, Sudafed, Benadryl)
Heartburn pill (Prevacid, Prilosec, Nexium, Zantac)
Tobacco
Vaping
None of the above
List any other medications/supplements you take and the medical condition for which you take them.
Allergies
Are you allergic to any of the following?
*
Tape
Latex
Betadyne/iodine skin prep
None of the above
Do you have any allergies to medications? If so, to which medications are you allergic and what is your body's reaction?
*
Your personality
On a scale from 1 (easy going) to 5 (perfectionist), how would you describe your personality?
*
1 - easy going
2
3
4
5 - perfectionist
We take pride in meeting and exceeding our patients’ vision goals, even for those with a perfectionistic personality! At the same time, it’s important to have reasonable expectations about what modern laser and lens implant eye surgery can do and what it can’t do. Please take time to share your vision goals and expectations with your doctor at your BVOA.
*
I understand
Your doctors
Name and office location of your primary care physician.
*
What is the date of your last appointment with your primary care physician?
MM slash DD slash YYYY
Name and office location of any eye doctors you have seen in the past five years.
*
Past LASIK candidacy
Have you ever been told that you are a candidate for LASIK or vision correction surgery?
*
Yes
No
List any doctor/facility where you were determined to be a LASIK or eye surgery candidate. How many years ago was this testing completed?
*
Which modern laser/lens eye correction procedures were offered to you?
*
LASIK
PRK
Visian ICL or Toric ICL
Small incision lenticule extraction (SMILE)
Refractive lens exchange (RLE)
Light adjustable lens RLE
KAMRA near vision inlay
Questions for Brinton Vision doctor
If you have any specific questions or concerns you would like Dr. Poore, Dr. Brinton, or Dr. Chesnut to address, list them here.
Lifestyle
Are there hobbies you enjoy or wish you could enjoy more without glasses or contacts? How do you use your eyes outside of the workplace?
Check common reasons for wanting to have LASIK that apply to you.
*
See alarm clock clearly
Fall asleep in bed watching a movie or TV
Wear regular sunglasses
See during an emergency without stopping to find glasses or put in contacts
Travel
Swimming
Skiing, snowboarding, snow sports
Simplify morning and evening routine
Improved eye comfort / eye health
Mask wear fogging up glasses / drying contacts
Safety benefits of clear eyesight
Other
Are there activities you enjoy or wish you could enjoy more without glasses or contacts? How do you use your eyes outside of the workplace?
How long have you considered improving your eyesight with LASIK?
*
<3 months
3-12 months
1-2 years
many years
If our doctor determines that you are a candidate for laser vision correction, how soon are you wanting treatment?
*
as soon as possible
next few weeks
next few months
in three months or more
Paying for your LASIK / vision correction procedure
How do you plan to pay for your care? Check all that apply. Please note that insurance does not cover laser vision correction procedures because they are not considered a medical necessity.
$0 down, 0% interest deferred financing
$0 down & low monthly payments with a fixed interest rate for 60 months
Flex Spending (FSA) funds
Health Savings Account (HSA) funds
Cash, check, or credit card
We believe that financial considerations should not be an obstacle to obtaining the clear vision you deserve. At Brinton Vision, our goal is to make vision correction procedures fit any budget. Patients may obtain pre-approval for financing, if desired, by clicking one of the following links:
-
Alphaeon
-
GreenSky
Upload any prescriptions or chart notes from previous eye doctor visits
Providing a photograph or scan of the following can be helpful to our team. (optional)
- previous eye records
- any eye prescriptions
- picture of contact lens boxes showing numbers
Max. file size: 50 MB.
Upload a scanned eye prescription or any records
Max. file size: 50 MB.
Disclosures
For internal training purposes only, Brinton Vision may record, with audio equipment, your preoperative exam. This is an important part of our dedication to provide a patient experience focused on you. If you are uncomfortable with this you may opt out here.
*
Opt in
Opt out
Please arrive at our office fifteen minutes prior to your appointment time to check in. Late arrivals will be asked to book a new appointment.
*
I understand
Our doctors and medical technicians may communicate with you via phone, text, email, or voicemail. We also routinely provide medical updates to your other care providers to ensure the highest quality of care.
*
I understand
You are required to show a driver license or government-issued photo ID for us to scan upon arrival at your first appointment. Your appointment will be rescheduled if you are unable to provide this.
*
I understand
By typing my full name below, I affirm and certify that the information and answers to questions herein are complete, true, and correct to the best of my knowledge and belief.
*
