Medical History Questionnaire
Mr. Mrs. Ms:*
E-mail:*
Work Phone:
Last Eye Exam:
Last Medical Exam:
Date of Birth:
Employer:
Occupation:
Describe how you use your vision at work so we can make the best lens recommendations for you:
What kinds of hobbies, sports, and other interests do you have? Knowing this enables us to find the best vision correction for you:
Who can we thank for referring you to our office:
Personal History
Do you wear contacts?
If so, which type?
Choose the type below.
rigid
soft
hard
extended wear
If so, which brand?
Are your contact lenses comfortable?
Are you pregnant or nursing?
Have you had any major injuries, surgeries and/or hospitalizations?
If so, please list them below.
Do you take any medications?
If so, please list them below.
Do you currently have or had the following conditions? Check those that apply.
Allergic/Immunologic
Bones/Joints/Muscles
Cardiovascular
Constitutional
Dermatologic
Ears, Nose Throat
Endocrine
Eyes
Gastrointestinal
General Health
Genitourinary
Hematologic/Lymphatic
Psychiatric
Respiratory
Vascular Disease
Other:
Family History
Does any family member (parents, grandparents, siblings, children) currently have or had any of the following conditions? Please write the relationship to you.
Other:
Health History Update
Payment Policy *
We will do all we can to find out what your vision insurance benefits are and what you are eligible for. We will also submit your claim for you. The information given to us by your insurance company is not a guarantee of payment from them. If your insurance company does not pay this amount it will be your responsibility to pay your balance. To the best of my knowledge, the above information is correct.
Privacy Policy *
Please read and acknowledge that you have received a copy of the doctor's Notice of Privacy Practices. Review policy
By clicking, I acknowledge I have read the above
