Questionnaire for Existing Patients – Medicare and PPO Please take time to help us make sure we keep appropriate records and address your concerns. Step 1 of 5 20% NameEmailNew AddressYesNoAddressStreet AddressAddress Line 2CityState / Province / RegionZip / Postal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongoCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCountryMedical HistoryDescribe any changes in treatment and conditions since your last exam.A brief description of the reasons for your visit Review Of SystemsCircle all that apply and provide a brief explanationConstitutionalFever, Weight Loss/GainYesNoNeurologicalHeadachesYesNoMigrainesYesNoSeizuresYesNoEyesLoss of VisionYesNoBlurred VisionYesNoDistorted Vision/HalosYesNoLoss of Side VisionYesNoDouble VisionYesNoDrynessYesNoMucous DischargeYesNoSandy or Gritty FeelingYesNoItchingYesNoBurningYesNoForeign body sensationYesNoExcess Tearing/WateringYesNoGlare/Light SensitivityYesNoEye Pain or sorenessYesNoChronic InfectionYesNoEyelid RednessYesNoTired EyesYesNoFlashes/floatersYesNoEars, Nose, Mouth, ThroatAllergies / Hay FeverYesNoSinus CongestionYesNoRunny NoseYesNoPost-Nasal DripYesNoChronic DripYesNoDry Throat / MouthYesNoRespiratoryAsthmaYesNoChronic BronchitisYesNoEmphysemaYesNoVascular / CardiovascularDiabetesYesNoHeart PainYesNoHigh Blood PressureYesNoVascular DiseaseYesNo GastrointestinalDiarrheaYesNoConstipationYesNoGenitourinaryGenitals/Kidney/BladderYesNoEndocrineThyroid/Other GlandsYesNoLymphatic/HematologicAnemiaYesNoBleeding ProblemsYesNoBones/Joints/MusclesRheumatoid ArthritisYesNoMuscle PainYesNoJoint PainYesNoAllergic/ImmunologicAllergic/ImmunologicYesNoPsychiatricPsychiatricYesNoExplanation Medical InsurancePlease fill out as we are a medical eye care practice and need this information.Medical Insurance Company*Policy/ID number*Provider telephone number*Policy holder's name*Date of birth of primary insured* List any medications you takeIncluding oral contraceptives, aspirin, over the counter medications, please include dosage and frequency of use. Payment PolicyI have read and agree to the Payment Policy and Frame and Lens Policy
