New Patient Medical History Questionnaire & Consent

MEDICAL HISTORY QUESTIONNAIRE

Redstone Eye Associates
For patients new to our practice or have not been seen in the past 3 years or more by our Doctors, please fill this form completely. You will need to fill this form out, even if you have been to a different LensCrafters location, as we are not affiliated.
Patient Information
Patient Full Name*

First NameLast Name
If Minor, Parent or Guardian Full Name

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Email*
example@example.com
Emergency Contact*
Emergency Contact Name
Emergency Contact Phone Number

Area CodePhone Number
Your Occupation
Last Eye Doctor
Last Eye Exam

MonthDayYear
Date
Primary Care Doctor*
PCP Phone Number

Area CodePhone Number
Ocular History
Check if you have any of the following:*

Reading DifficultiesCrossed or Lazy EyeCataractEye InjuryGlaucomaMacular DegenerationLASIK or Eye SurgeryNone aboveOther
Do you wear glasses?*

NoYes, for seeing far away (example: driving or board at school)Yes, for seeing up close or near (example: reading or computer)
If you do wear glasses, how often do you wear them?

All the timeOnly on occasion or as needed
Do you wear contact lenses?*

NoNo, but I am interested in tryingYes, soft contact lensesYes, hard contact lenses (rigid gas perm)Yes, extended wear (sleeping in them)
Contact Lens Solution Brand
Medication, Allergies and Injury, Surgery or Hospitalization
Medication*
List any medication you take, including eye drops, vitamins, or over the counter. If you are not taking any medication, please type None.
Allergies*
List your allergies to medication. If you do not have any allergies, please type None.
Injury, Surgery or Hospitalization*
List any major injuries, surgeries or hospitalizations you have had. If you do not have any injury, surgery or hospitalization, please type None.
Family History
Have any of your relatives, living or deceased, had any of these conditions?*

NoneBlindnessCataractCrossed EyesGlaucomaMacular DegenerationRetinal DiseaseArthritisCancerDiabetesHeart DiseaseHigh Blood PressureKidney DiseaseLupusThyroid DiseaseHigh CholesterolOther
Social History
Do you drive?*

NoYes, with no problemsYes, with visual difficulties
Do you use tobacco products?*

NoYes
Do you drink alcohol?*

NoYes
Do you do illegal drugs?*

NoYes
Review of Systems
Do you currently, or have you ever had any problems in the following areas?
Allergic or Immunologic*

NoneEczemaAllergies or Hay FeverOther
Bone, Joints, Muscles*

NoneRheumatoid ArthritisMuscle PainJoint PainGoutOther
Cancer*

NoneBreastProstateLungOther
Constitutional*

NoneFeverWeight Loss or GainOther
Ear, Nose, Mouth, Throat*

NoneSinus CongestionFrequent ColdsPost-nasal DripChronic CoughDry Throat or MouthOther
Endocrine*

NoneHyperthyroidHypothyroidOther
Eyes*

NoneLoss of VisionBlurred VisionDistorted Vision or HalosLoss of Side VisionDouble VisionDrynessMucous DischargeRednessSandiness or Grittiness FeelingItchinessBurningForeign Body SensationExcess Tearing or WateringGlare or Light SensitivityEye Pain or SorenessChronic Infection of Eye or LidSty or ChalazionFloatersTired EyesFlashes of LightOther
Gastrointestinal*

NoneDiarrhea or ConstipationCrohn's DiseaseOther
Genitourinary*

NoneGenitals, Kidney or BladderOther
Lymphatic & Hematologic*

NoneAnemiaBleeding ProblemsOther
Neurological*

NoneHeadachesMigrainesSeizuresOther
Psychiatric*

NoneAnxietyDepressionOther
Respiratory*

NoneAsthmaChronic BronchitisEmphysemaOther
Skin*

NoneRosaceaAcneOther
Vascular & Cardiovascular*

NoneDiabetesHeart ConditionHigh Blood PressureHigh CholesterolBrain Injury or StrokeOther
Patient Consent and Signature
Section 1: Optomap Retinal Exam
The optomap® Retinal Exam:
- Is fast, easy, and comfortable
- Provides a permanent record for annual review
- May alleviate the need for dilation
An optomap® Exam gives us a panoramic image of the surface of your retina. These images help the doctor assess the health of your eyes and check for conditions including macular degeneration, glaucoma, and retinal detachments. These problems can threaten vision, sometimes without warning or symptoms.

Serious health problems unrelated to the eye such as diabetes, hypertension, heart disease, some cancers, and auto-immune disorders, can also be detected with an optomap® Exam. Early detection could help save your vision or your life.

The cost of the optomap® Exam is only $40. (You may use your HSA or Flex Spending Account)
I understand that the optomap® retinal exam will be performed at my exam and do not have any questions.
Section 2: Dilation
We take pride in performing comprehensive eye examinations on all of our new and existing patients. Dilation is a part of the comprehensive exam in which the doctor uses eye drops to temporarily enlarge your pupils in order to examine the inside of your eyes. Dilation of the eye can aid in the detection of glaucoma, cataracts, retinal detachments, tumors, diabetes, and high blood pressure even before the onset of any symptoms or loss of vision. Dilating your pupils may result in temporary blurred vision and increased sensitivity to light for up to 4 hours. It is advisable to have a driver especially if this is your first time dilating your eyes.
There is NO additional fee for dilation. Please indicate your preference below:*

Yes, I consent to have my eyes dilated today.No, I do not consent to have my eyes dilated today. I understand that dilation is a part of my comprehensive eye exam, and I am responsible for scheduling my dilation appointment. Further, I understand that a condition with the potential for partial or total vision loss may exist, and it may go undetected without dilation.
Section 2: Contact Lens Fit and Evaluation
I understand that contact lenses are medical devices regulated by FDA and an annual eye exam and contact lens fitting or evaluation is necessary for all contact lens wearers. This is important to make sure my prescription is up-to-date, to keep my eyes are healthy and that no ocular or visual complication exists with contact lens use. I also understand that I am responsible for this separate non-refundable fee, which most insurance plans do not cover.
Please indicate your preference below:*

Yes, I consent to be fitted or evaluated for contact lenses today and aware of additional fee.No, I do not consent to be fitted or evaluated for contact lenses and understand that I will not have a valid prescription for contact lenses.
Consent to Provide your Contact Lens Prescription Electronically:

I consent to having my contact lens prescription provided to me upon request via email, when the prescription has been finalized or in the future.
Section 3: Health Insurance Release
For Patients Using Vision or Health Insurance: I authorize the release of any medical information necessary to provide my insurance claims. I also authorize payment of medical benefits directly to the Doctor. I understand that if my insurance company denies payment in whole or part, then I am responsible for those fees. To dispute an non-covered claim, I must contact the insurance company directly.
Please indicate your preference below:*

By signing below, I have read and acknowledge this Health Insurance Release.This does not apply to me as I will not be using any vision or health insurance for this visit.
Section 4: Medicare Advance Beneficiary Notice of Non-coverage (ABN)
For Medicare Patients: I understand that Refraction (a procedure that determines my glasses prescription) and Digital Retinal Imaging Screening are not considered medically necessary by Medicare and is a non-covered charge. I understand if I choose to have it done, I am responsible for these fees.
Please indicate your preference below:*

By signing below, I have read and acknowledge the Medicare ABN.This does not apply to me as I am not a Medicare patient.
Section 5: Notice of Privacy Practice
We are required by applicable Federal and State law to maintain the privacy of your health information. We are also required to give our patients our Notice about our privacy practices, our legal duties and your rights concerning your health information.
Please check to acknowledge the following:*

By signing below, I have read and acknowledge the presentation of the Notice of Privacy Practices for Redstone Eye Associates and has been offered a copy of said policy to keep in patient's own record.
Section 6: Insurance Information
In light of COVID-19, we are required to check patient's insurance benefits and eligibility in advance. Please kindly provide BOTH your health and vision insurance information below if you have not given us your information.
Please include the name(s) of your insurance and member ID.
If you prefer not to use any insurance for your examination please check below:

I will be self paying for my examination.
Section 7: Confirmation and No-Show Policy
Due to limited availability, we require our patients to confirm their appointment by 3PM the night prior to their scheduled appointment (unless the appointment was made same day). If you do not confirm your appointment via text, phone, email or checking below, your appointment will be cancelled. Additionally, there is a $40 fee if you do not show up to your appointment.
Please check to acknowledge the following:*

I understand Redstone Eye Associates' Confirmation and No-Show Policy. By checking here, I am confirming my appointment.
Signature
Patient or Parent/Guardian Signature *

Clear
Today's Date*

MonthDayYear
Date
Additional Questions or Concerns.
COVID-19 Policy
Redstone Eye Associates is committed to providing exceptional eye care while keeping you and our staff healthy and safe. Please be aware of our COVID-19 Policy:

1. Wearing a mask is required to enter the office and is to be worn during your exam.
2. Social Distancing is a priority. To help limit the number of patients in our office, we ask that only the patient with the scheduled appointment is allowed. One parent or guardian is also allowed if the patient is a minor.
3. Prior to coming into our office, please call us at (781) 438-3372 when you arrive at the Redstone Shopping Plaza.
4. COVID-19 Symptoms and Exposure questions will be asked and your temperature will be taken prior to being seen.
5. To practice social distancing, we have limited appointments available. Please kindly call our office at least 24 hours in advance at 781-438-3372 if you need to reschedule or cancel your appointment.
WE LOOK FORWARD TO SEEING YOU SOON!

Thank you for taking the time to fill out this form!
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MEDICAL HISTORY QUESTIONNAIRE

Patient Information

Ocular History

Medication, Allergies and Injury, Surgery or Hospitalization

Family History

Social History

Review of Systems

Patient Consent and Signature

Section 1: Optomap Retinal Exam

Section 2: Dilation

Section 2: Contact Lens Fit and Evaluation

Section 3: Health Insurance Release

Section 4: Medicare Advance Beneficiary Notice of Non-coverage (ABN)

Section 5: Notice of Privacy Practice

Section 6: Insurance Information

Section 7: Confirmation and No-Show Policy

Signature

COVID-19 Policy

WE LOOK FORWARD TO SEEING YOU SOON!