Check all the items that pertain

Do you wear glasses? 

Are you interested in refractive surgery?

When do you wear glasses?   For distance and near For distance For near

Are you unhappy with your glasses?

Do you have trouble seeing with your glasses?

Do you wear contact lenses?

Do your eyes bother you?

Do you get headaches?

Besides wearing glasses do you have or have you had any eye condition which required treatment?

Do you have or is there a family history of diabetes, glaucoma, or hypertension?

Do you have any other health problems?

Do you take any medications?

What is the major reason for making this appointment?


Anything else you would like us to know?

BRING YOUR EYE GLASSES AND CONTACT INFORMATION WITH YOU AND/OR IF YOU KNOW YOUR CONTACT LENS INFORMATION COMPLETE THE SECTION BELOW:

Material: Soft Toric Soft Gas Permable Hard If you wear a toric contact lens do not fill in the above, bring in your lens information

Eye              Power         Base Curve             Diameter         Type                Brand  

Right    - +   1 2 3 4 5 6 7 8 9 10 11 12 . 00 25 50 75     8 7 9 .                      

Left      - +   1 2 3 4 5 6 7 8 9 10 11 12 . 00 25 50 75     8 7 9 .                      

 If checked please read checked items:

_x__ I understand that many medical plans such as GHI, United Health, Aetna (US Health) do not pay for refraction (determination of your eyeglass prescription). In some cases there may be an additional fee for this service ($65). I wish to have this service performed. yes; no; need to ask the doctor. (All refractive services are included with VSP)

_x__ I understand that most medical plans do not pay for contact lens evaluations ($95). (Refitting of contact lenses is additional to the contact lens evaluation). I want this service performed. yes; no; need to ask the doctor


I authorize the release of any medical information necessary to process all medical claims.

Patient's signature: _________________________________ Date:_____________________

I authorized the release of payment for medical benifits to my physician.

Patients signature: ___________________________________ Date:_____________________
 

Additional Medical History (Review of Systems)
 

Print this form and bring to your examination. Thanks