Medical History Form

Note: The word "you" in this form refers to THE PATIENT.

Parents and other guardians completing this form should be careful about this
PATIENT HISTORY QUESTIONNAIRE

Thank you for selecting our office! PLEASE BRING YOUR EYEGLASSES AND INFORMATION ABOUT YOUR CONTACT LENSES (if any) TO YOUR APPOINTMENT!
Take Personal (Headshot) Photo Now to Submit (optional)
Take Photo of your PRIMARY HEALTH INSURANCE card here [e.g. Medicare, Highmark, etc.](strongly recommended) Try to avoid reflections in the photo. PLEASE BRING YOUR CARD WITH YOU TO YOUR APPOINTMENT!
Take Photo of your SECONDARY HEALTH INSURANCE card here [e.g.AARP] (if any) (strongly recommended) Try to avoid reflections in the photo. PLEASE BRING YOUR CARD WITH YOU TO YOUR APPOINTMENT!
Take Photo of your VISION CARE PLAN card here [e,g. VSP, EyeMed, VBA, Davis] (if any) (strongly recommended) Try to avoid reflections in the photo.
Full Name of the Patient*

First NameMiddle NameLast NameSuffix
Patient Gender*
Birth Date of the Patient*

MonthDayYear
Full Name of the PERSON WHOSE INSURANCE WILL BE USED FOR THE APPOINTMENT (sometimes referred to as the Subscriber or Member or Policyholder)*

First NameMiddle NameLast NameSuffix
Birth Date of the PERSON WHOSE INSURANCE WILL BE USED FOR THE APPOINTMENT (sometimes referred to as the Subscriber or Member or Policyholder)*

MonthDayYear
The patient would like the doctor and staff to call them (say their name as):
Whom may we thank for referring you, or, how did you find our office?
Address of Patient*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home (Landline) Phone Number of Patient
Work Phone Number of Patient or Parent/Guardian
Cell Phone Number of Patient or Parent/Guardian
Emergency Contact Person and Relationship to Patient
Emergency Contact Person Telephone Number
SSN of Patient (ask our staff if this is needed in your case)
To help protect your privacy, we only wish to collect this information if it is required to verify insurance coverage.
Occupation of Patient
To help us asses your likely visual needs
Hobbies or pastimes of patient
To help us assess your likely visual needs
Employer
Often helps us to narrow down your insurance benefits and get to know you a bit better
Date of Patient's Last Eye Examination by an Eye Doctor

MonthDayYear
Date
Previous Eye Doctor and Location of Eye Doctor's Office
This can be helpful in obtaining your past eye care records should it be needed.
Present Family Physician or Internist and Location*
This can be helpful in obtaining your past medical records should it be needed, or forwarding a report to your doctor.
Does the patient have any physical, intellectual, or emotional disability, English language difficulty, communication problem, or hearing impairment that will require any special accommodation (e.g., unusual amount of time for examination by the doctor, need for a translator, or need for special adapted testing?*
If you answered yes to the question above in regards to special needs or accommodations, please explain in detail here:
Are you pregnant?*
Are you nursing (breastfeeding)?*
Main Reason for Office Visit*
Main concern or problem to be taken care of
If the patient is under 18 years old or otherwise has a legal guardian, name of parent(s) or guardian(s), and address if different from the patient
Do you plan to ask the doctor to be evaluated or re-evaluated for contact lens wear (required if you intend to seek a contact lens prescription).*

Yes, I plan to start or continue wearing contact lenses after my exam with the doctor.No, I don't wear contact lenses and have no intention of pursuing contact lens wear at this timeI am not sure about this and need to discuss it with the doctor at my exam.
Please take a moment to review or download our thin booklet “Financial and Other Practice Information for Patients” located directly below this question frame. It contains very important and helpful information about what we can and should expect of one another in our doctor-patient relationship here at Davis Hawley Eyecare.*

I have reviewed and/or downloaded the thin booklet mentioned and have read or will read it before I come to my appointment at Davis Hawley Eyecare. OR ...I will request a paper copy of this information when I arrive in the office.
Please review this information which will be very helpful in understanding how the office operates and what we can expect of each other before, during, and after your visit.
If you plan to have a contact lens evaluation, please review our contact lens policy. If you elect to have your contact lens evaluation with us, this policy is not optional. (i.e,, you must agree to abide by the policy or to not be evaluated for contact lenses with us).
If you are considering a Myopia Management Program for your 6 to 18 year old child, or for yourself if you are under age 25, please review an outline of our Myopia Management Program policies here.
Browse Files

Cancelof
To help you spell your medications correctly, you may wish to check them on www.drugs.com in a separate browser tab.

Current Medications (including eyedrops, injections, nutritional/herbal supplements, and/or vitamins that you take): (Please write in NONE if you don't take any medications).*

	Name of Substance	Dose (e.g. 200 mg)	Frequency (e.g., pills per day or uses per day; e.g. 2x per day)	Route of Administration (oral, nasal, IV, IM, inhaler,subcutaneous,transdermal,rectal, vaginal,otic)	Condition or Disease for which medication is being taken
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10
Medication 11
Medication 12
Medication 13
Medication 14
Medication 15

Allergies to Medications, Foods or Other Substances (Please write NONE if you have no allergies to report).*

	Substance Name	Reaction to substance (hives, swollen tongue, GI upset, etc.)
Substance 1
Substance 2
Substance 3
Substance 4
Substance 5
Substance 6

Eye Surgeries / Laser Treatments (Please write NONE if you have never had surgery or laser)*

	Type of Surgery (e.g. LASIK, cataract, retinal detachment)	Date of Procedure	Complications, if any
Procedure 1
Procedure 2
Procedure 3
Procedure 4
Procedure 5

Patient history of eye injury *

YesNo
If yes to eye injury, give details including date:
e.g. list if hospitalized or resulted in loss of vision
Please check off the eye problems that you know you have had:*

NoneStrabismus (an eye turn)Amblyopia (poor vision due to strabismus or large refractive error).CataractDry EyeHerpes Virus infection of eyeRetinal DetachmentMacular DegenerationRetinal DiseaseConjunctivitsUveitisCorneal ulcerGlaucoma or glaucoma suspectOther
Do you wear eyeglasses? (now or in the past year)*

YesNo
Do you wear contact lenses (now or in the past year)*

YesNo
Are you currently being treated, or have you at any time in the past been treated, for any EYE disease or disorder?*

YesNo
If you answered yes to the above question about current or previous treatment of eye disease/disorder, please explain the basics of your treatment:
Do you currently use tobacco (either smoking or smokeless tobacco)?*

YesNo
Have you ever used intravenous drugs (other than as administered by doctor, EMT, nurse, or hospital)?*

YesNo
Do you have children (no matter their age)?

YesNo
Do you have any hobbies or special interests you would like to tell us about? This can help us to understand your optical/visual needs and help us to get to know you a bit better.
Are you licensed to drive a motor vehicle?*

YesNo
Are you presently, or have you been in the past, diagnosed with diabetes or pre-diabetes?*

YesNo
If you have been diagnosed with diabetes, what was the approximate date of your diagnosis?

MonthDayYear
Date
If you have been diagnosed with diabetes or pre-diabetes, enter your last known hemoglobin A1c number:
If you answered yes to the above question about diabetes, which treatments are you CURRENTLY using?
Please mark any of the conditions that YOU currently have or previously had: (Please check NONE if you have had none of the listed conditions)*

NoneAllergiesAlzheimer's Disease/dementiaAnemia/bleeding problemsArthritis (osteo or rheumatoid)Asthma/chronic bronchitisBlindnessBlood TransfusionCancerDepressionEmphysema/COPDEpilepsy/SeizuresGlaucomaKidney/Urinary problemsUlcer/stomach problemsOsteoporosisNight sweatsHeart problemsHepatitis A,B, or CHigh blood pressureHigh cholesterolHIV/AIDSLupusMigraineSickle Cell AnemiaStrokeThyroid DiseaseTuberculosisOther Disorder
Please list any details about the conditions in the question above that you would like us to know about:

FAMILY HISTORY of eye problems:*

	Yes	No	Which Relative Had Problem?
Blindness
Retinal Detachment
Corneal Problem
Macular Degeneration
Glaucoma
Other

REVIEW OF SYSTEMS

Required by medical insurance carriers and helpful in your overall care! Hang in there - you're almost done! PLEASE CHECK IF YOU ARE EXPERIENCING ANY OF THE FOLLOWING SYMPTOMS:
Health in general:*

No problemsChillsFatigueFeverWeight GainWeight LossOther
Skin:*

No problemsExcessive drynessItchingSkin lesionRash (Eczema, psoriasis, rosacea)Other
Ears, Nose, Mouth, Throat:*

No problemsSinus painEar dischargeEar painHearing lossTinnitus (ringing/buzzing/swoosh)Nasal CongestionNosebleedsRhinorrhea (runny nose)HoarsenessSore throatOther
Cardiovascular*

No problemsChest painClaudication (leg pain/cramping)Dyspnea on Exertion (shortness of breath with effort)Leg SwellingOrthopnea (shortness of breath while laying down)PalpitationsOther
Respiratory*

No problemsCoughHemoptysis (coughing up blood)Shortness of breathSputum productionWheezingSleep apnea - with or without CPAPOther
Gastrointestinal*

No problemsAbdominal painBelchingBlood in stoolConstipationDiarrheaHeartburnHemorrhoidsNauseaTrouble swallowingVomitingOther
Genitourinary*

No problemsIrregular MensesBladder IncontinencePolyuria (frequent urination)Dysuria (painful urination)Other
Muscle, Joint, and Bone*

No problemsBack painFallsJoint painMyalgia (muscle pain)Neck painOther
Neurological*

No problemsDizzinessFocal WeaknessHeadacheLoss of ConsciousnessSeizuresSpeech ChangeNumbness/TinglingTremorOther
Psychiatric*

No problemsDepressionHallucinationsInsomniaMemory LossNervous/anxiousOther
Allergic / Immunology*

No problemsEnvironmental allergiesOther
Blood and Lymph*

No problemsEasy bruising / bleedingLymph node swellingOther
Glands and Endocrine*

No problemsHot flashesPolydipsia (frequent thirst)Excessive SweatingOther
I hereby authorize Dr. Hawley to examine and treat my condition as deemed appropriate through the use of optometric / medical services, and give authority for these procedures to be performed. The patient (or parent/guardian in the case of a minor or person in guardianship) agrees that he/she is responsible for all bills incurred at this office.
Signature*
Date and Time

MonthDayYear
DateHourMinutesAM/PM Option
No Show / No Cancellation Fee - $50.00

Kindly give us 24 hours NOTICE of inability to keep your appointment to avoid our $50.00 per patient NO-SHOW fee. Multiple no-shows within a 2 year period will not be rescheduled.
You DO NOT need to print this form unless you want it for your own records. Just PLEASE BE SURE TO *Click on Submit* below when it is complete.
Thank You!
Should be Empty:

Note: The word "you" in this form refers to THE PATIENT.

PATIENT HISTORY QUESTIONNAIRE

To help you spell your medications correctly, you may wish to check them on www.drugs.com in a separate browser tab.

REVIEW OF SYSTEMS

No Show / No Cancellation Fee - $50.00