(shortness of breath, wheezing)
Heart Problems
Endocrine Problems
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Clarkson Eyecare
PATIENT HISTORY QUESTIONNAIRE
(completion required at each patient appointment)
Welcome to our office
Title ( ) Last name
(Mr., Mrs., Ms., Miss, Dr.)
First name
MI
Date
Name you wish to be called
E-Mail
Home Address
City
State
Zip
Age
Birthdate
SSN
Employer/School
Occupation
Cell
Name of Parent, Legal Guardian or Spouse
Home
Work
Name of family members whom we have provided care
Insurance Company
ID#
Subscriber name
Relationship to patient
Birthdate
Primary Care Physician:
Pediatrician:
Referred By
Subscriber
Pregnant/Nursing
List any previous major injuries/surgeries/hospitalizations:
Medical History /
Review of Systems:
List any medications you are now taking (including eye drops, birth control pills, vitamins or over the counter medications):
Are you allergic to any medications?
Do you have or have you ever had any of the following problems:
Respiratory Problems
Gastrointestinal Problems
Urinary Problems (pain or discomfort, blood in urine)
Skin Problems (rashes, excessive dryness, rosacea)
Neurologic (numbness, weakness, headaches, prior stroke)
Psychiatric Problems (depression, anxiety)
Chronic fever, unexpected weight loss/gain, fatigue
Ear/nose/throat (hearing loss, sinus)
Yes
No
Please list:
Other Condition/Illness
No
No
No
No
No
No
No
No
No
No
No
Preferred Pharmacy:
Seasonal Allergies
Diabetes
Thyroid Problems
High Blood Pressure
Arthritis
Asthma/COPD
(ulcer, abdominal pain, diarrhea)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
(Please mark preferred)
Eye History: Do you have or have you ever had any of the following problems:
Blurred Vision
Cataracts
Double Vision
Dry Eye
Eye Injury
Eye Surgery
Flashes
Floaters
Glaucoma
Lazy/Crossed Eye
Loss of Vision
Macular Degeneration
Migraine/Headache
Retinal Detachment
Family History
(Mother, Father, Grandparents, Siblings)
Blindness
Cataract
Glaucoma
Lazy/Crossed Eye
Macular Degeneration
Retinal Detachment
Diabetes
High Blood Pressure
Other Eye Disease or Condition:
Race (Optional):
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Ethnicity (Optional):
Not Hispanic or Latino
Hispanic or Latino
Preferred Language:
Are you interested in correcting your vision with LASIK Surgery?
Yes
No
High Cholesterol
Location:
Phone:
Yes
No
Musculoskeletal Problems
Clarkson Eyecare
PATIENT HISTORY QUESTIONNAIRE
(completion required at each patient appointment)
Last eyecare provider:
Date of last eye exam
Are you currently having eye or vision problems?
Yes
No
If yes, please explain
Do you wear glasses?
Yes
No
Yes
No
How old are they?
Are they bifocals?
Are they for
Reading
Distance
Both
Have you ever worn contact lenses?
Yes
No
If yes, when were they prescribed?
Do you wear contacts now?
Yes
No
If not, why did you quit?
Are you interested in wearing contact lenses?
Yes
No
1. Specific curvature measurements of the corneas
2. Evaluation of current and new lenses to ensure optimal fit, vision and comfort
3. Medical assessment of the cornea, tear film and conjunctiva as they relate to contact lens wear
4. Instructions regarding safe contact lens wear, care and proper cleaning and solutions
5. Contact lens follow up care for 90 days
If you have any questions, please do not hesitate to speak with your doctor.
Payment for all services and products is the responsibility of the patient.
I agree to pay all copays, deductibles, co-insurances and non-covered services as determined by my insurance company.
I understand there is a returned check fee applied to every returned check.
I agree to pay an additional collection fee for all accounts not paid in the time stated on the final monthly statement.
I authorize the release of medical information concerning my illness and treatment by Clarkson Eyecare to my insurance company.
I also authorize the release of my personal medical information to any doctor whom I may be referred to.
I understand verification of eligibility is not a guarantee of payment as stated by my insurance company.
I authorize payment of my insurance benefits to Clarkson Eyecare.
We will file all insurance forms if Clarkson Eyecare is a participating provider for your plan.
We will supply you with an itemized statement which you may submit to your insurance carrier.
PAYMENT IN FULL IS REQUIRED AT TIME OF SERVICE
If yes, please read the following information regarding contact lenses.
Clarkson Eyecare prescribes quality contact lenses to improve your vision and your lifestyle. Contact lenses are FDA regulated medical devices that can cause discomfort, infections, and even permanent vision loss if not cared for properly. New and existing contact lens wearers require additional time and testing during an eye examination to minimize the risk of serious eye problems. This additional testing is only done for contact lens wearers, not for patients who do not wear contact lenses. For this reason, there are additional contact lens evaluation and services fees for new and existing contact lens wearers. Your contact lens evaluation and services fee includes:
Marital Status:
Single
Married
Other
Do you drive?
Yes
No
If yes, do you have visual difficulty when driving?
Yes
No
If yes, please describe:
Smoking History
Current Every Day Smoker
Current Some Day Smoker
Former Smoker
Never Smoker
Smoker (Current Status Unknown)
Do you drink alcohol?
Yes
No
Do you use illegal drugs?
Yes
No
Have you ever been exposed to or infected with:
HIV
Hepatitis
If patient is 18 or under, please complete:
Any prenatal, perinatal, or postnatal problems?
Yes
No
Any developmental problems?
Yes
No
Do you have any concerns with your child's school performance?
Signature of patient or legal guardian
Today's Date
Updated May 2011