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Spex Express Medical History Form

Medical History Questionnaire
Last Name:
First Name:
Middle Initial:
Street Address:
City:
State:
Zip Code:
Home Phone: -
Work/Cell Phone: -
Occupation or Grade of Patient:
Employer of Responsible Party:
What is the major reason for your exam?
Today's Date: / /   mm/dd/yyyy
Date of Birth: / /   mm/dd/yyyy
Last Eye Exam: / /   mm/dd/yyyy
Medical Doctor:
Doctor's Phone: -
Last Medical Exam: / /   mm/dd/yyyy
Vision Insurance:
Primary Medical Insurance:
Secondary Medical Insurance:
Insurance Holder's name:
Insurance Holder's Date of Birth: / /   mm/dd/yyyy
Medical History
Do you have any allergies to medication? Yes No
If yes, explain.
List any medications you take (including oral contraceptives, asprin, over the counter medications and home remedies).
List any major injuries, surgeries and/or hospitalizations you have had.
List any of the following you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections or eye injury.
Are you pregnant and/or nursing? Yes    No
Do you wear glasses? Yes    No
If yes, how old is your present pair of lenses?  yrs
Do you wear contact lenses? Yes    No
If yes, how old is your present pair of lenses?  yrs
Type of contact lenses: Rigid Soft Extended Wear Other
Are they comfortable? Yes    No


Family History
Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions: 
Disease/Condition No Yes ? Relationship To You
Blindness
Cataracts
Crossed Eyes
Glaucoma
Macular Degeneration
Lazy Eye
Retinal Detachment/Disease
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Lupus
Thyroid Disease
Other 

Social History
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you perfer.
Yes, I would prefer to discuss my Social History information directly with my doctor (check box)  
No Yes If yes, type/amount/how long?
Do you drive?
If yes, do you have visual difficulty when driving?
If yes, please describe.
Do you use tobacco products?
Do you drink alcohol?
Do you use illegal drugs?
Have you ever been exposed to or infected with:
Gonorrhea
Hepatitis
HIV
Syphilis
Review of Systems
Do you currently, or have you ever had any problems in the following areas?
SYSTEM No Yes ?
CONSTITUTIONAL
Fever, Weight Loss/Gain
INTEGUMENTARY (SKIN)
NEUROLOGICAL
Headaches
Migraines
Seizures
EYES
Loss of Vision
Blurred Vision
Distorted Vision/Halos
Loss of Side Vision
Double Vision
Dryness
Mucous Discharge
Redness
Sandy or Gritty Feeling
Itching
Burning
Foreign Body Sensation
Excess Tearing/Watering
Glare/Light Sensitivity
Eye Pain or Soreness
Chronic Infection of Eye or Lid
Sties or Chalazion
Flashes/Floaters in Vision
Tired Eyes
ENDOCRINE
Thyroid/Other Glands
EAR, NOSE, MOUTH, THROAT
Allergies/Hay Fever
Sinus Congestion
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Throat/Mouth
RESPIRATORY
Asthma
Chronic Bronchitis
Emphysema
VASCULAR/CARDIOVASCULAR
Diabetes
Heart pain
High Blood Pressure
Vascular Disease
GASTROINTESTINAL
Diarrhea
Constipation
GENITOURINARY
Genitals/Kidney/Bladder
BONES/JOINTS/MUSCLES
Rheumatoid Arthritis
Muscle Pain
Joint Pain
LYMPHATIC/HEMATOLOGIC
Anemia
Bleeding Problems
ALLERGIC/IMMUNOLOGIC
PSYCHIATRIC
If you answered YES to any of the above or have a condition not listed, please explain & list medications:

Personal Questionnaire
This form will allow us to learn more about you on a personal level. Thank you for your time.
Are you a male or female?   Male   Female
Do you have an e-mail address?   Yes   No
If so, what is it?
Do you want new glasses today?   Yes   No
Are you interested in laser vision correction?   Yes   No
Are you interested in contact lenses?   Yes   No
If yes, do colors interest you?   Yes   No
Are you interested in sunglasses?   Yes   No
 

Contact Lens History
If you do not currently wear contact lenses please skip this section! Thank you!!
What brand of contacts do you wear?
What material?   Soft   Hard  Toric   Bifocal
Have you had any problems with your contact lenses?   Yes   No
If yes, please explain:
How often do you replace your contact lenses?
Do you sleep in your contact lenses?   Yes   No
How many hours/day do you wear your contact lenses?
How many days/week do you wear your contact lenses?

VERY IMPORTANT!
New patients: Whom may we thank for referring you to our office?
Name a friend or relative:
If not referred, how did you choose our office for visual needs? Please check an answer.   Relative
  Another doctor
  Friend
  Insurance list
  Signs
  Yellow pages
  Already established patients
  Other:

Occupational and Recreational
What activities do you do at work? Please check all that apply.   Driving
  Computers
Accounting
  Filing
  Detailed work
  Extensive Reading
  Dangerous work (safety goggles)
If you uses a computer, how many hours a day?  hrs
Do you ever wear lenses while using the computer?   Yes   No
When computing do your eyes get tired?   Yes   No
When computing does the glare bother you?   Yes   No
What recreational activites do you participate in?   Reading
  Racquetball
  Tennis
  Golf
  Swim
  Ski
  Fishing
  Basketball
  Biking
  Other:
How many hours are you usually in the sun for?  hrs
Do you wear sunglasses while in the sun?   Yes   No
Do you wear glasses that have anti-reflective coating?   Yes   No

Enter the code as you see it above.

Payment Terms
The staff at Spex Express is more than willing to assist you in filling your insurance claims. If your insurance will not pay the aniticipated amount, or your insurance pays you directly, we ask that you please pay the balance. Office policy calls for payment at the time of service. If eye care or contact are ordered, a minimum of 50% deposit is requested and the American Express, and all debit cards for you personal convenience. Interest will be added to all accounts with unpaid balances.
I have been notified and offered a copy of Spex Express Notice of Privacy Practive Policy.