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Riverchase Galleria, Hoover - 205-985-7612
Proudly serving residents of Central Alabama including
Hoover, Vestavia and Pelham
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Contact Us

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Contact Information

Riverchase Galleria

 

  • Medical History Questionnaire

    Patient Name: Mr. Mrs. Ms. Dr. __________________________________Today’s Date: _____/_____/______

    Home: _______________Cell: _________________Work: _______________Email: _______________________________

    Street: ____________________________________ City: ______________________ State: ________ Zip:______________

    Birth Date: ______/______/__________ Social Security #: _______-_______-_________ (required)

    Name of Medical Dr. /Clinic: _____________________________________Last Medical Exam:________/________/______

    Previous Eye Dr. /Clinic: _______________________________________ _Last Eye Exam: ________/________/_________

    Occupation: ____________________________________ Employed By: __________________________________________

    Insurance Policy Holder: __________________________Policy Holder Birth Date: ________/_________/_______________

    Primary Insurance Co: _________________________ ID #: ________________________ Group #:____________________

    Secondary Insurance Co: _______________________ ID #: ________________________ Group #:____________________

    Medical Release/Lifetime Signature on File/Payment Authorization:

    I authorize payment for all Medicare and/or other insurance benefits for services rendered to be made payable to Complete Eyecare, PLC. I authorize this

    office to release to the Centers for Medicare and Medicaid and its agents or any other insurer any information necessary to determine the benefits payable

    for related services. I agree to be financially responsible for any balance not paid by my vision or medical plan. This form will also serve as a lifetime

    signature form. Please note that failure to sign above does not absolve you from your financial obligation to pay for the services provided to you or

    your family member today.

    Patient or Guardian Signature: _____________________________________________ Date: _______/______/_____________

    Medical History:

    Do you have any allergies to medications? No Yes If yes, please list: _______________________________________

    _________________________________________________________________________________________________________

    List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies):

    ____________________________________________________________________________________________________

    ____________________________________________________________________________________________________

    Are you pregnant and/or nursing? no yes If yes, how many weeks? _____________________________________

    Do you wear glasses? no yes If yes, how old is the prescription?_______________________________________

    Do you wear contact lenses? no yes If yes, how old is your current pair of lenses?_________________________

    If not, are you interested in contact lenses? no yes

    Type of contact lenses worn: Rigid Soft Continuous Wear Other Are they comfortable? no yes

    Are you considering refractive surgery / LASIK at any time in the future? no yes If yes, how soon? __________

    Ophthalmic History: none cataracts glaucoma lazy eye drooping eyelid prominent (bulging) eyes

    retinal disease crossed eyes eye infections eye injury macular degeneration

    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

    Cataract

    Crossed Eyes

    Glaucoma

    Macular Degeneration

    Retinal Detachment/Disease

    Arthritis

    Cancer

    Diabetes

    Heart Disease

    High Blood Pressure

    Kidney Disease

    Thyroid Disease

    Lupus

    Other

    Social History:

    (This information is kept strictly confidential. However, you may discuss this portion directly with your doctor if you prefer.)

    Yes, I would prefer to discuss my Social History information directly with my doctor.

    Do you drive: No Yes If yes, do you have any visual difficulties when driving? No Yes If yes, describe:

    _________________________________________________________________________________________________

    _________________________________________________________________________________________________

    Do you use tobacco products? No Yes If yes, type/amount/how long:

    Do you drink alcohol? No Yes If yes, type/amount/how long:

    Do you use recreational drugs? No Yes If yes, type/amount/how long: ________________________________

    Have you ever been exposed to or infected with any of the following? No Gonorrhea Hepatitis HIV Syphilis

    Review of Systems:

    Do you currently or have you ever had any problems in the following areas?

    System No Yes ? System No Yes ?

    CONSTITUTIONAL PSYCHIATRIC

    Fever, Weight/Loss/Gain Depression

    INTEGUMENTARY (Skin) EARS/NOSE/MOUTH/THROAT

    NEUROLOGICAL Environmental Allergies/Hay Fever

    Headaches/Migraines Sinus Congestion/Runny Nose

    Seizures Chronic Cough

    ENDOCRINE RESPIRATORY

    Thyroid/Other Glands Asthma

    EYES Chronic Bronchitis

    Loss of Vision/Side Vision Emphysema

    Blurred Vision VASCULAR/CARDIOVASCULAR

    Distorted Vision/Halos Diabetes

    Flashes/Floaters in Vision Heart/Vascular Disease

    Double Vision High Blood Pressure

    Excess Tearing/Watering GASTROINTESTINAL

    Dryness Diarrhea

    Sandy or Gritty Feeling Constipation

    Foreign Body Sensation GENITOURINARY

    Mucus Discharge Genitals/Kidney/Bladder

    Itching/Burning BONES/JOINTS/MUSCLES

    Redness Rheumatoid Arthritis

    Eye Pain or Soreness Joint Pain

    Chronic Infection/Eye or Lid Muscle Pain

    Glare/Light Sensitivity LYMPHATIC/HEMATOLOGIC

    Sties or Chalazion Anemia

    Tired Eyes Bleeding Problems

    ALLERGIC/IMMUNOLOGIC

    If you answered YES to any of the above or have a condition not listed, please explain:

    _____________________________________________________________________________________________________

    _____________________________________________________________________________________________________

    _____________________________________________________________________________________________________

    ______________________________________ ______________

    Doctor’s Signature Date
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