Medical History Flemington Name* First Last Date Date Format: MM slash DD slash YYYY Vision plans cover “routine” eye exams. Some medical plans will only cover the visit if there is a medical reason for the visit, such as loss of vision, eye redness, eye discomfort, dry eyes, glaucoma, cataracts, floating spots, etc. If we are able to use your medical insurance to cover the visit, you will have to pay both the specialist copay as listed on your insurance card and the refraction fee (refraction is the part of the exam that determines your eyeglass prescription) We will help as much as possible to determine coverage, but ultimately, you are responsible for referrals and fees not covered or applied to your deductible. For current contact lens wearers or those who want to be fit for contact lenses, there is an additional fee (other than the eye exam fee) for the evaluation and measurements necessary to determine the health, safety and proper lens selection for the eyes. This includes any wearing instructions, starter solutions/kits, and any follow-up visits to complete the fitting/evaluation, as determined by the doctor. These measurements and lens needs can change and will need to be re-evaluated over time. Please initial that you understand the above statements:Are you interested in purchasing new glasses today?YesNoDo you currently wear contact lenses?YesNoAre you interested in contact lenses?YesNoAre you interested in Laser Vision Correction?YesNoREASON for VISIT: How can we help you today? Please tell us below the main eye/vision problem that you are having:Are there any associated symptoms?Does anything alleviate the symptoms?Review of Systems:Do you or any family member have or ever had the following? (Please check if “Yes”)YouFamilyYou and FamilyAllergiesArthritisAsthmaAutoimmune DisorderCancerDiabetesGastrointestinal DiseasePsychiatric DisordersThyroid DiseaseGlaucomaLazy EyeHeadacheHeart DiseaseHigh Blood PressureHigh CholesterolLung ProblemsNeurological ProblemsGenito/UrinarySkin ConditionsEye/Head InjuryEye SurgeryOther Eye DiseaseFemales:Are you pregnant?YesNoHow many months?Are you nursing?YesNoPlease list any medications you are taking now: Are you a:Current SmokerFormer SmokerNever SmokedHow many years ago did you quit?Alcohol use:SociallyDaily UseNeverAny drug allergies?NoYesPlease list PhoneThis field is for validation purposes and should be left unchanged.
