Please complete the information below and submit the form online or, if you prefer, print out the form after full or partial completion and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection. Patient Information Name *
Today's Date *
Address City ZIP Code Home Number *
Please provide a telephone number, with area code, so we can contact you.
Cell Phone Work Phone Email Address
Please provide your email address.
Employer Occupation Date of Birth *
Social Security Number (last 4 digits only!) Date of Last Eye Exam
Last Medical Exam
Medical History Do you have any allergies to medications? If Yes, list medication(s) and reaction below: List any medications you take including oral contraceptives, aspirin, OTC medicines, etc.:
Include Name of Medication, Dosage, Frequency Taken
List all major injuries, surgeries and/or hospitalizations you have had: Check any of the following that you have had: If Other Eye Disorders, please explain: Are you pregnant or nursing? Do you wear glasses? If Yes, how old is your present pair of lenses? Do you wear contact lenses? If Yes, how old is your present pair of lenses? Type of Contact Lenses: Are they comfortable? Family History
Note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.
Disease/Condition If Other, please explain: Social History
This information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer. Please check the box below of you prefer to discuss with the doctor instead.
I prefer to discuss my Social History information directly with my doctor. Do you drive? If Yes, do you have visual difficulty when driving? Do you drink alcohol? Have you ever been exposed to or infected with: REVIEW OF SYSTEMS
Do you currently or have you ever had any problems in the following areas?
Neurological Headaches Migraines Seizures Eyes Loss of Vision Blurred Vision Dryness Redness Sandy or Gritty Feeling Itching Burning Excess Tearing/Watering Eye Pain or Soreness Flashes/Floaters in Vision Tired Eyes Endocrine Thyroid/Other Glands Elevated Cholesterol Cancer Ears, Nose, Mouth, Throat Sinus Congestion Dry Thoat/Mouth Allergies/Hay Fever Respiratory Asthma Vascular/Cardiovascular Diabetes High Blood Pressure Bones/Joints/Muscles Rheumatoid Arthritis Lymphatic/Hematologic Anemia Allergic/Immunologic Allergic/Immunologic Psychiatric Psychiatric Patient Signature Date
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