Medical History Form

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.

Please provide the following personal information to help us serve you better.

• Name (First, Middle, Last) *
• Today's Date *
• Address (Street, City, Province/State, Postal Code, Country) *
• Home Number * — Please provide a telephone number with area code.
• Cell Phone
• Work Phone
• Email Address
• Employer
• Occupation
• Date of Birth *
• Social Security Number (last 4 digits only)
• Race/Ethnicity
• Preferred Language
• Gender
• Who may we thank for referring you to our office?
• Date of Last Medical Exam
• Name of Medical Doctor
• Doctor's Phone Number
• Date of Last Eye Exam
• Current Height
• Current Weight
• Spouse or Guardian (If Applicable)

• Do you have any allergies to medications? If yes, list medication(s) and reaction.
• List any medications you take including oral contraceptives, aspirin, OTC medicines, etc. (Include name, dosage, frequency taken)
• List all major injuries, surgeries and/or hospitalizations you have had.
• Check any of the following that you have had: Crossed Eyes, Lazy Eye, Drooping Eyelid, Prominent Eyes, Cataracts, Glaucoma, Iritis/Uveitis, Macular Degeneration, Retinal Disease or Detachment, Eye Infections, Eye Injury, Corneal Problems, Other Eye Disorders
• 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? Type: Rigid, Soft, Extended Wear, Other — Are they comfortable?

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: Blindness, Cataract, Crossed Eyes, Glaucoma, Macular Degeneration, Retinal Detachment or Disease, Arthritis, Cancer, Diabetes, Heart Disease, High Blood Pressure, Kidney Disease, Lupus, Thyroid Disease, Other

If yes to any of the above, please provide details and relationship.

This information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer.

• Do you drive? If yes, do you have visual difficulty when driving?
• Do you use tobacco products? If yes, list type/amount/how long.
• Do you drink alcohol? If yes, list type/amount/how long.
• Do you use illegal drugs? If yes, list type/amount/how long.
• Have you ever been exposed to or infected with: Gonorrhea, Hepatitis, HIV, Syphilis

Do you currently or have you ever had any problems in the following areas? (Yes / No)

Constitutional

• Fever, Weight Loss/Gain
• Integumentary (Skin)

Neurological

• Headaches
• Migraines
• Seizures

Eyes

• Loss of Vision
• Blurred Vision
• Distorted Vision/Halos
• Loss of Side Vision
• Double Vision
• Dryness
• Mucous Discharge
• Redness
• Sandy or Gritty Feeling
• Itching
• Burning
• Foreign Body Sensation
• Excess Tearing/Watering
• Glare/Light Sensitivity
• Eye Pain or Soreness
• Chronic Infection, Eye or Lid
• Sties or Chalazion
• Flashes/Floaters in Vision
• Tired Eyes

Endocrine

• Thyroid/Other Glands
• Elevated Cholesterol
• Cancer

Ears, Nose, Mouth, Throat

• Sinus Congestion
• Runny Nose
• Post-Nasal Drip
• Chronic Cough
• Dry Throat/Mouth
• Allergies/Hay Fever

Respiratory

• Asthma
• Chronic Bronchitis
• Emphysema

Vascular/Cardiovascular

• Diabetes
• Heart Pain
• High Blood Pressure
• Vascular Disease

Gastrointestinal

• Diarrhea
• Constipation

Genitourinary

• Genitals/Kidney/Bladder

Bones/Joints/Muscles

• Rheumatoid Arthritis
• Muscle Pain
• Joint Pain

Lymphatic/Hematologic

• Anemia
• Bleeding Problems

Allergic/Immunologic

• Allergic/Immunologic

Psychiatric

• Psychiatric

If you answered Yes to any of the above review of systems questions or have a condition not listed, please explain and list any related medications when you meet with your doctor.

Please provide your Patient Signature and Date at the time of submission.

You may submit this form online or print it and bring it to our office. For questions, please contact us at 236-420-7222.