visionsourceodessa - Medical History Questionnaire

Medical History Questionnaire

Name

Email *

example@example.com

SSN

Address

Street Address

City State

Zip Code

Phone

Area Code Phone Number

Age

Birth Date

Gender

Male Female

Marital Status

Married Single

Race

American Indian/Alaska Native Asian Black or African American Hispanic Native Hawaiian/Other Pacific Island White

Ethnicity

Hispanic or Latino Native Hawaiian/Other Pacific Island Not Hispanic or Latino

Employer

Work Phone

Area Code Phone Number

Occupation or Grade if a student

Last eye doctor

Last eye exam

Medical doctor

Doctor Phone

Area Code Phone Number

Email

Last medical exam

If a minor, Father's name

Father's work phone

Area Code Phone Number

Mother's name

Mother's work phone

Area Code Phone Number

What are your hobbies?

Have we seen family members?

Yes No

if yes, please list

How did you hear about our office?

Newspaper Phone book Mail out Other

Whom may we thank for referring you?

MEDICAL / FAMILY HISTORY

Do you have any allergies to medications?

Yes No

If yes, please explain

List any medications you take

	Medications	Reason for medications	Doctor that prescribed
1
2
3
4
5

List all major injuries, surgeries, and/or hospitalizations

List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections and/or eye injury

Are you pregnant or nursing?

Yes No

Do you wear glasses?

Yes No

Type of glasses?

Distance Near Bifocal

Do you wear contact lenses?

Yes No

Lens care system

Type of contact lens

Hard Soft Other

Are you interested in learning more about laser surgery?

Yes No

Are you planning to get new eyeglasses today?

Yes No

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

Are you interested in contacts?

Yes No

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

Are you allergic or sensitive to any contact solutions?

Yes No

Are they comfortable?

Yes No

Do you currently. or have you ever had any of the following problems

	Yes	No
Loss of vision
Blurred vision
Distorted vision/Halo
Loss of side vision
Double vission
Dryness

	Yes	No
Foreign body sensation
Excess tearing/watering
Glare/light sensitivity
Eye pain/ soreness
Chronic infection of eye/lid
Sties or chalazion

	Yes	No
Mucous discharge
Redness
Sandy/gritty feeling
Flashes/Floaters
Tired eyes
Itching

Please indicate if any of the Disease/Condition apply to you or a family member (blood relative only)

	Who	Relationship(Blood Relative Only)
Blindness
Cataract
Eye Turn
Glaucoma
Macular Degeneration
Retinal Detachment/Disease

REVIEW OF SYSTEMS

Please indicate below if you have or ever had problems with the following conditions

Allergic/Immunologic

None Lupus (SLE) Rheumatoid Arthritis Environmental Allergies Seasonal Allergies Other (i.e, Latex)

Ear and Throat

None Sinusitis Upper Respiratory Tract Infection

Gastrointestinal

None Crohn's Disease Colitis Acid Reflux/Ulcer

Skin/Integumentary

None Eczema Rosacea Psoriasis

Psychiatric

None Depression Bi•Polar Schizophrenia

Cardiovascular

None High Blood Pressure Heart Disease Stroke Vascular Disease High Blood Cholesterol

Endocrine / Glands

None Diabetes Hormone Dysfunction Thyroid Dysfunction

Respiratory

None Asthma Bronchitis Emphysema

Muscle/Skeletal

None Arthritis Fibromyalgia Ankylosing Spondylitis

Genital/Urinary

None Urinary Tract Infection HIV Positive Herpes/Chlamydia

Hematologic/Lymphatic

None Anemia Leukemia Bleeding Disorder

Neurological

None Multiple Sclerosis Epilepsy Tremors

General Health

None Weight loss/gain Fever Fatigue Trauma

SOCIAL

Tobacco Use

Yes No

Smoke?

Current Smoker Former Smoker

Recreation drugs

Alcohol Consumption

Weight

Height

INSURANCE INFORMATION

Vision Insurance

Member's Name

Member's ID #

Insurance Type

Medicare Medicaid Supplemental Insurance

Medicare No

Medicaid No.

Supplemental Insurance

Member's Name

Member's ID

Method of payment

Cash Check Credit Card Insurance

I

Request Refuse

a copy of Vision Source Privacy Policy

I have read and answered the above questions to the best of my knowledge. I authorize Vision Source to release information as to exam, diagnosis or treatment rendered to me or my child to third party payers and/or health practitioners. I will be responsible for all charges that are not covered or paid by my policy. I am aware that the contact lens fitting and follow-up care may not be covered under the "exam" definition in my policy. I understand that my prescription will be given to vendors in order for Vision Source to be able to process my materials. I further understand that payment is due at the services are rendered unless prior arrangements are made.

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Date