History Questionnaire

MEDICAL HISTORY QUESTIONNAIRE

Dear Patient,
All major health insurers and Medicare now require us to obtain in depth patient medical history information. We apologize for the time required to fill out this form and thank you for your cooperation.

Today's Date:
Full Name:
Address:
City State Zip:
Home Phone:
Work Phone:
Your SS#:
Date of Birth:
Sex:
Age:
Occupation:
Employer:
Insured's Name:
Insureds SS#:
Primary Care Physician:
Last Medical Exam:
Last Eye Doctor:
Last Eye Exam:
Your E-Mail:
How did you hear about us:
Medical History: Reason for Visit:
Routine Annual Exam:
Contact Lenses:
New Glasses:
Lost Or Broken Glasses:
Interested in Lasik Laser Vision Correction:
Do you have questions:
Are you allergic to any medications:
Are you pregnant or nursing:
List Medications:
Personal Eye History:
Have you ever worn glasses:
How old are your glasses:
Do you wear contacts:
Type of contact lenses: Disposables Gas Perm Soft Bifocal Other
Have you ever had lasik or refractive surgery:
If yes to surgery date:
Have you ever had eye surgery:
Check any of the following that you have had:	Crossed Eyes Lazy Eye Drooping Eyelid Prominent Eyes Glaucoma Retinal Disease Cataracts Eye Injury Serious Eye Infection
How many hours day do you work on a computer:
Review of Systems Do you currently or have you ever had any serious problems in the following areas:
Check any of the following that you have had:	Diabetes Blood Pressure Neurological/Headaches Cholesterol Eyes Cancer Skin Allergic/Immune Blood Endocrine/Thyroid Ears, Nose, Mouth, Throat (Allergies) Respiratory Cardiovascular Gastrointestinal Musculoskeletal Mental
Other:
If you answered YES to any of the above or are currently under the care of a physician for any condition not listed above please explain in space provided above. Social History: This information is kept strictly confidential. Please answer all questions that apply.
Do you drive? Yes No If yes, do you have visual difficulty when driving? Yes No
If yes, please describe:
Do you use tobacco products? Yes No
Do you drink alcohol? Yes No
Do you use illegal drugs? Yes No Family History: Please note any family history (parents, grandparents, sibiling, children: living or deceased) for the following conditions: Disease/Condition
Glaucoma: Yes No - Relationship
Macular Degeneration: Yes No - Relationship
Cataract: Yes No - Relationship
Retinal Detachment/Disease: Yes No - Relationship
Diabetes: Yes No - Relationship
High Blood Pressure: Yes No - Relationship
Crossed Eyes: Yes No - Relationship
Blindness: Yes No - Relationship
Arthritis: Yes No - Relationship
Cancer: Yes No - Relationship
Heart Disease: Yes No - Relationship
Kidney Disease: Yes No - Relationship
Lupus: Yes No - Relationship
Thyroid Disease: Yes No - Relationship
Other:
I acknowledge that I have been made aware of the HIPPA Notice of Privacy Practices. Patients Name:
Date:
Your Comments:

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Medical History:

Personal Eye History: