Midlothian Optometric Center
Patient Questionnaire

Full Name:			Male:		Female:
Address:		City:			State:
Home#:	Work#			Cell#:
Occupation:	Date of Birth:			Social Security #:

Reason for Today's Visit:

Referred by: Email Address:

Insurance Information
Vision Insurance

Name of Plan:
Member Name:
Member ID #:
Member Date of Birth:
Group #:

Medical Insurance

Name of Plan:
Member Name:
Member ID #:
Member Date of Birth:
Group #:

Patient History

Do you have any Allergies? No: If Yes, explain:
Are you Pregnant and/or Nursing? No: Yes:
Are you a Diabetic? No: Yes:
Do you wear Glasses now? No: Yes:
Do you wear contact Lenses now? No: If Yes, what type?:
Do you have problems with your eyes burning, itching, or tearing? No: Yes:
Have you had any eye injuries or surgeries? No: If Yes, explain:
Do you use a computer? No: If Yes, How often?:
Do you work in an environment that requires Safety Eyewear? No: Yes:
Check any of the following that you have had:
Crossed Eyes:
Lazy Eye:
Drooping Eyelid:
Glaucoma:
Retinal Disease:
Cataracts:
Eye Infections: diagnosis:
List any medications you currently take, including oral contraceptives, aspirin, or over-the-counter type:


Review of Systems
Please check any of the following that describe a condition that you currently have or have ever had a problem with:
Headaches Migraines Seizures Loss of Vision Blurred Vision Distorted Vision/Halos
Loss of Side Vision Double Vision Dry Eyes Mucous Discharge Sties Flashes/Floaters
Glare/Light Sensitivity Eye Pain Redness Excess Tearing Allergies/Hay Fever Asthma Sinus Congestion Dry Throat/Mouth Bronchitis Emphysema High Blood Pressure
Rheumatoid Arthritis Joint Pain

Family History

Blindness	Yes No Not Sure If Yes, what Relation?
Cataract	Yes No Not Sure If Yes, what Relation?
Glaucoma	Yes No Not Sure If Yes, what Relation?
Macular Degeneration	Yes No Not Sure If Yes, what Relation?
Arthritis	Yes No Not Sure If Yes, what Relation?
Diabetes	Yes No Not Sure If Yes, what Relation?
Thyroid Disease	Yes No Not Sure If Yes, what Relation?
Heart Disease	Yes No Not Sure If Yes, what Relation?
Cancer	Yes No Not Sure If Yes, what Relation?
Other	Yes No Not Sure If Yes, what Relation?

Social History

Do You Drive?	Yes No If Yes, Do you have any visual difficulties?
Do You Use Tobacco Products?	Yes No If Yes, what type/amount/how long?
Do You Drink Alcohol?	Yes No If Yes, what type/amount/how long?

For patients using insurance: in regards to any outstanding balance or co-payments not covered by your insurance, payments are due 30 days from the date of invoice, and service charges in the amount of 1.5% per month (18% per annum) will be assessed for any amount past due. The undersigned agrees to pay all cost of collection, including court costs and 33 1/3% attorney fees.

Patient Signature_____________________________________ Date_____________________

WE APPRECIATE YOUR ANSWERS AS THEY WILL ALLOW US TO PROVIDE THE BEST POSSIBLE EYECARE TO YOU.