Discerning Eye

Patient Information and Medical History Questionnaire

Name

First Last

Responsible Party

If under 18 years of age

First Last

Date

Birth Date

Age

Sex

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Phone Number

Home	Work	Cell

Occupation

Employer

Vision Insurance Company

Number

Medical Insurance Company

Number

Policy Holder

Relationship to Patient

Policy Holder Date of Birth

How were you referred to our office?

Previous Patient
Advertisment
Website
Yellow Pages
Drove/Walk By

Ocular History

Date of last eye exam

Name of optometrist/ophthalmologist

Check any of the following which my apply:

If other, please list below

Do you wear glasses?

Yes
No

If yes, how old is your present pair of lenses?

Does glare from oncoming headlights or your computer bother you?

Yes
No

Do you wear contact lenses?

Yes
No

If yes, how old is your present pair of lenses?

Are your contact lenses comfortable?

Yes
No

I replace my lenses every

What solutions do you use for cleaning and disinfecting your contact lenses?

Family History

Please check any family history (parents, grandparents, siblings, children) for the following conditions:

Medical History

Name of Physician

Date of last medical exam

Address

City State / Province / Region

List any allergies to medications:

List any medication you take (include oral contraceptive, over the counter medications and home remedies):

Are you currently pregnant and/or nursing a child?

Yes
No

Social History

This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.

Do you use tobacco products?

Yes
No

If yes, please state type/amount/how long your use.

Do you drink alcohol?

Yes
No

If yes, please state type/amount/how long your use.

Review of Systems

Do you currently, or have you ever had any problems in the following areas:

Constitutional

Fever
Weight Loss/Gain

Neurological

Headaches
Migraines
Seizures

Endocrine

Thyroid Dysfunction
Other Glands

Ear/Nose/Mouth/Threat

Allergies/Hayfever
Sinus congestion
Runny Nose
Dry Throat/Mouth

Respiratory

Asthma

Integumentary (Skin)

Yes

Psychiatric

Yes

Vascular/Cardiovascular

Diabetes
Heart Pain
High Blood Pressure
Vascular Disease

Gastrointestinal

Abdominal Pain

Genitourinary

Kidney
Bladder

Bones/Joints/Muscles

Rheumatoid Arthritis
Muscle Pain
Joint Pain

Lymphatic/Hematologic

Anemia
Bleeding Problems

Immunological

Yes

If you checked any of the boxes above or have a condition not listed, please explain:

Authorization

I certify that I have read and understood the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the eye doctor to release any information including the diagnosis and the records of treatment or examination rendered to me or my child during the period of such eye care to third party payers and/or health practitioners. I authorize and request that my insurance company to pay directly to pay directly to the eye Doctor insurance benefits otherwise payable to me. I understand that my eye care insurance may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Signature of patient (or parent if minor)

Date

HIPAA Consent

I do herby consent and acknowledge my agreement to the terms set forth in the HIPAA information Form and any subsequent changes in office policy; I understand that this consent shall remain in force from this time forward.

Date