Health History Questionnaire

Medical History Questionnaire

Please be sure to bring your medical/vision insurance card, any eyewear, contact lenses to your appointment.
GENERAL INFO
Patient Name

First NameLast Name
Patient Gender
Patient Birth Date

MonthDayYear
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Patient E-Mail
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Will you be using insurance today?
- Vision Insurance
  
  Other
- Vision ID or Social Security Number
- Primary Insured Name
  
  First NameLast Name
- Prmary Insured Date of Birth
  
  MonthDayYear
- Medical Insurance
  
  Other
- Medical Insurance ID
- What brings you in today?
- Please explain in detail your chief complaint
  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.
- Please check any signs or symptoms you are experencing:
  
  Other
- Location: Which eye?
- Progression?
- How long has it been going on?
- Are you taking or doing anything to improve it?
- CURRENT VISION
- Do you currently wear GLASSES?
- Do you current wear CONTACT LENS?
- SOCIAL HISTORY
- Do you or have you smoked?
- Do you consume alcohol?
- FAMILY HISTORY
- Has anyone in your family been diagnosed with any of the following (Check all that apply)
  
  Other
- Has anyone in your family been diagnosed with any of the following eye problems (Check all that apply):
  
  Other
- REVIEW OF SYSTEM
  
  Please select all that apply:
- OCULAR/EYE
  
  Other
- CARDIOVASCULAR
  
  Other
- ENDOCRINE
  
  Other
- RESPIRATORY
  
  Other
- NEUROLOGICAL
  
  Other
- SKIN
  
  Other
- PSYCHIATRIC
  
  Other
- MUSCULOSKELETAL
  
  Other
- BLOOD/LYMPH
  
  Other
- ALLERGY/IMMUNOLOGIC
  
  Other
- GASTROINTESTINAL
  
  Other
- GENITOURINARY
  
  Other
- LIST ALL CURRENT MEDICATIONS:
- LIST ANY MED/OTHER ALLERGIES:
- Are you currently pregnant or nursing?
- Acknowledgement of Notice of Privacy Practices
- 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.
- Signature *

Medical History Questionnaire

GENERAL INFO

CURRENT VISION

SOCIAL HISTORY

FAMILY HISTORY

REVIEW OF SYSTEM

Acknowledgement of Notice of Privacy Practices