Kid's Eye Site

Medical History Questionnaire

Name

First Last

Gender

Male
Female

Today's Date

Address

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

Birth Date

Home Phone

Cell Phone

Preferred way of contact

Text
Call

Has the patient ever had an eye exam?

Yes
No

Were glasses prescribed at this time?

Yes
No

Date of Last Exam

Name of Previous Eye Doctor

City

Guardian/Alternative Contact Information

Name

First Last

Relationship to Patient

Phone

Insurance Information

Primary Member's Name

First Last

Birth Date

Social Security Number

Insurance Group and Number

Secondary Insurance Group and Number

Primary Medical Doctor

City

Medical History

Personal/Family History Please indicate if the patient or any family members have a history of any of the following:

Patient History

Family History

Other Health Conditions

Allergic to medications?

No
Yes

If yes, explain:

List any medications currently taking:

Ethnic Origin:

ANSWER IF UNDER 18:

Has the child been exposed to Tobacco products, Alcohol, or Recreational drugs?

Yes
No

If yes, explain:

Was the child born premature?

Yes
No

Has the child ever had a seizure?

Yes
No

Is the patient being treated for ADD/ADHD?

Yes
No

If yes, medication?

Assignment of Benefits Authorization

By signing below I understand that I am responsible for the balance on my account for any professional services rendered by Kid's Eye Site, regardless of my insurance status. I understand that it is my responsibility to pay any deductible amount, co-insurance or any remaining balance left unpaid by my insurance provider.

Notice of Privacy Practices

By signing below I acknowledge that I have had the opportunity to read Kid's Eye Site's Notice of Privacy Practices and Financial Policy.

Name

First Last

Signature

Date