Health History Questionnaire

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.

AetnaBlue Cross Blue ShieldCignaOther

Routine exam, no complaintsContact Lens Exam in addition to routine examMedical Visit

NOTE: Vision plans only pay for a basic, routine eye exam. Any medical complaints will be billed to medical insurance or will be charged out of pocket. If you experience any of the signs or symptoms below, the visit might be considered a medical visit.

Right eyeLeft eyeBoth eyes

ImprovingWorseStable

YES-Single VisonYES-Multifocal/PAL/No-line BifocalYES-Lost/BrokenNO

YES-Soft DAILY DisposableYES-Soft MONTHLY DisposableYES-Hard/RGPNO-Interested/1st time wear

YES-Cigarettes/Cigar/PipesYES-No longer smokingNO-Never Smoke

YES - OccasionallyYES-DailyNO

TuberculosisCOPDAsthmaOther

RosaceaPsoriasisEczemaOther

DepressionAnxietyOther

FibromyalgiaMuscular dystrophyOsteoarthritisOther

AnemiaBleeding disorderOther

ColitisCrohn's diseaseUlcerOther

Prostate disease/cancerSTDKidney diseaseOther

The law requires that HONEST EYECARE make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:

Initial I was given the opportunity to read, have read or had explained to me HONEST EYECARE's Notice of Privacy Practice prior to any services offered.
Intial The Notice of Privacy Practice could not be read due to the emergent nature of the care and will be acquired when possible

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.

Yes, I do want the visual field testing. I understand that this screen test is not covered by insurance and cost an additional $30.No, I DO NOT want the visual field testing.

Yes, I DO want the iWELLNESS test that will photo-document my retina and scan the back of my eye for any diseases, tumors, or other abnormalities. I understand that the screening test will be an additional and it might not be covered by vision insurance.No, I DO NOT want the iWELLNESS testing. I will sign a waiver indicating that I am declining additional testing that will allow my doctor to perform a full comprehensive exam.

I am waiving the iWELLNESS testing against the recommendation of my doctor and understand that the iWELLNESS will help my doctor perform the best comprehensive exam possible. Signature

Medical History Questionnaire

GENERAL INFO

CURRENT VISION

SOCIAL HISTORY

FAMILY HISTORY

REVIEW OF SYSTEM

Acknowledgement of Notice of Privacy Practices