PATIENT HISTORY QUESTIONNAIRE
                                                                         PLEASE PRINT

LAST NAME__________________________________FIRST NAME______________________________________MI____________

ADDRESS_____________________________________________________________________APT NO:______________________  

CITY_________________________________________________STATE______________ZIP________________________________

HOME PHONE_____________________________________BUSINESS PHONE___________________________________________

SSN________________________________________DATE OF BIRTH__________________________________________________

OCCUPATION_______________________________________________________________________________________________

EMPLOYER_________________________________________________________________________________________________

EMERGENCY CONTACT/TELEPHONE NO________________________________________________________________________

DATE OF LAST EYE EXAM________________________DILATED?_________TODAY'S DATE______________________________

MARRIED______  SINGLE______ DIVORCED________ OTHER_____

NAME OF SPOUSE  ____________________________________________________________________________

REASON FOR TODAY'S VISIT  __________________________________________________________________________________

HAVE YOU EVER HAD ANY EYE INJURY OR SURGERY?____________________________________________________________

HAVE YOU EVER HADE DOUBLE VISION, FLOATERS OR FLASHES?___________________________________________________
PLEASE DESCRIBE ANY HEADACHES YOU GET ON A REGULAR BASIS:  ______________________________________________
____________________________________________________________________________________________________________
CURRENT MEDICATIONS (INCLUDING OVER THE COUNTER EYE MEDICATIONS) ___________________________________________
____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
MEDICATION ALLERGIES OR SENSITIVITIES ________________________________________________________________________
_____________________________________________________________________________________________________________
ENVIRONMENTAL ALLERGIES OR SENSITIVITIES (HAY FEVER, LATEX, ETC.) _____________________________________________
_____________________________________________________________________________________________________________

FOR YOURSELF OR ANY BLOOD RELATIVE, IS THERE A HISTORY OF:

•	GLAUCOMA                        	_____ SELF	_____ RELATIVE	_____ NONE
•	CATARACTS	_____ SELF	_____ RELATIVE	_____ NONE
•	MACULAR DEGENERATION	_____ SELF	_____ RELATIVE	_____ NONE
•	RETINAL DISEASE OR DETACHMENTS	_____ SELF	_____ RELATIVE	_____ NONE
•	CROSSED OR LAZY EYE	_____ SELF	_____ RELATIVE	_____ NONE
•	OTHER EYE DISEASE	_____ SELF	_____ RELATIVE	_____ NONE
•	DIABETES	_____ SELF	_____ RELATIVE	_____ NONE
•	HEART DISEASE, HYPERTENSION	_____ SELF	_____ RELATIVE	_____ NONE
•	MULTIPLE SCLEROSIS	_____ SELF	_____ RELATIVE	_____ NONE
•	ARTHRITIS	_____ SELF	_____ RELATIVE	_____ NONE
•	CROHN'S DISEASE	_____ SELF	_____ RELATIVE	_____ NONE
•	ASTHMA, RESPIRATORY DISEASE	_____ SELF	_____ RELATIVE	_____ NONE
•	SYSTEMIC LUPUS	_____ SELF	_____ RELATIVE	_____ NONE
•	OTHER IMMUNE SYSTEM CONDITIONS	_____ SELF	_____ RELATIVE	_____ NONE
•	ANXIETY OR OTHER PSYCHOLOGICAL CONDITIONS	_____ SELF	_____ RELATIVE	_____ NONE
•	CURENTLY SMOKING?	______ YES	_____ NO
•	PREGNANT?	______ YES	_____ NO	          

OTHER EYE PROBLEMS?                                 Y/N      WHAT KIND?____________________________________________________________

DO YOU WEAR GLASSES?                             Y/N      CONTACT LENSES?       Y/N         TYPE_______________________________________

                                                                                 PAYMENT INFORMATION

RESPPONSIBLE PARTY TO PAY IF OTHER THAN PATIENT
(IF YOU HAVE A VSP GIFT CERTIFICATE THEN PUT "VSP GIFT CERTIFICATE")

NAME ___________________________________________________________________________________
 
ADDRESS ________________________________________________________________________________
 
CITY __________________________________________STATE____ZIP_______ HOME PHONE_____________

BUSINESS PHONE__________________SOCIAL SECURITY NUMBER _________________________________

DATE OF BIRTH _________________________

DO YOU HAVE VISION INSURANCE?  YES______  NO__________

                                                                               INSURANCE INFORMATION

INSURANCE COMPANYS NAME________________________________________________________________________

MEMBERS NAME _____________________________________________ DATE OF BIRTH ______________________

POLICY NUMBER ____________________________________ GROUP NUMBER ______________________________
(MAYBE THE MEMBERS SOCIAL SECURITY NUMBER)

CO-PAY ______________________________

PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED.  
 MEDICARE WILL NOT PAY FOR ROUTINE EYE EXAMINATIONS OR GLASSES UNLESS YOU HAVE HAD CATARACT SURGERY.  THEN THEY WILL ONLY PAY ONE TIME ON GLASSES.   

ADDITIONAL INFORMATION ___________________________________________________________________________________________

WHOM MAY WE THANK FOR REFERRING YOU?__________________________________________________________________________

DOCTOR'S INITIALS ___________________  

ATTESTATION:  THE INFORMATION PROVIDED IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.  IF ANY OF THIS INFORMATION SHOULD CHANGE, I WILL NOTIFY YOUR OFFICE PROMPTLY

PATIENT   SIGNATURE________________________________________________________________________________________________
DATE __________________________________________________