Medical History

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.

Name

First Last

Date

Please initial that you understand the above statements:

Are you interested in purchasing new glasses today?

Yes
No

Do you currently wear contact lenses?

Yes
No

Are you interested in contact lenses?

Yes
No

Are you interested in Laser Vision Correction?

Yes
No

REASON 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”)

	You	Family	You and Family
Allergies
Arthritis
Asthma
Autoimmune Disorder
Cancer
Diabetes
Gastrointestinal Disease
Psychiatric Disorders
Thyroid Disease
Glaucoma
Lazy Eye
Headache
Heart Disease
High Blood Pressure
High Cholesterol
Lung Problems
Neurological Problems
Genito/Urinary
Skin Conditions
Eye/Head Injury
Eye Surgery
Other Eye Disease

Gender?

Male
Female

Are you pregnant?

Yes
No

Are you nursing?

Yes
No

Please list any medications you are taking now:

Are you a:

Current Smoker
Former Smoker
Never Smoked

Alcohol use:

Socially
Daily Use
Never

Any drug allergies?

No
Yes

Existing Patient Forms

Step 1 of 2 - Medical Information

Medical History

Review of Systems:

Optos Consent