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.

Patient Information

Name*

First Middle Last

Today's Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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*

Preferred Language

Gender

Female
Male

Who may we thank for referring you to our office?

Date of Last Eye Exam

Spouse or Guardian (If Applicable)

Medical History

Do you have any allergies to medications?

No
Yes

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

Check any of the following that you have had:

If Other Eye Disorders, please explain:

Are you pregnant or nursing?

No
Yes

Do you wear glasses?

No
Yes

If Yes, how old is your present pair of lenses?

Do you wear contact lenses?

No
Yes

If Yes, how old is your present pair of lenses?

Type of Contact Lenses:

Rigid
Soft
Extended Wear
Other

Are they comfortable?

No
Yes

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:

If Yes to any of the above, 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.

Yes

REVIEW OF SYSTEMS

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

Neurological

Headaches

No
Yes

Migraines

No
Yes

Seizures

No
Yes

Eyes

Loss of Vision

No
Yes

Blurred Vision

No
Yes

Distorted Vision/Halos

No
Yes

Loss of Side Vision

No
Yes

Double Vision

No
Yes

Dryness

No
Yes

Mucous Discharge

No
Yes

Redness

No
Yes

Sandy or Gritty Feeling

No
Yes

Itching

No
Yes

Burning

No
Yes

Foreign Body Sensation

No
Yes

Excess Tearing/Watering

No
Yes

Glare/Light Sensitivity

No
Yes

Eye Pain or Soreness

No
Yes

Chronic Infection, Eye or Lid

No
Yes

Sties or Chalazion

No
Yes

Flashes/Floaters in Vision

No
Yes

Tired Eyes

No
Yes

Endocrine

Thyroid/Other Glands

No
Yes

Elevated Cholesterol

No
Yes

Cancer

No
Yes

Vascular/Cardiovascular

Diabetes

No
Yes

Heart Pain

No
Yes

High Blood Pressure

No
Yes

Vascular Disease

No
Yes

Bones/Joints/Muscles

Rheumatoid Arthritis

No
Yes

Lymphatic/Hematologic

Bleeding Problems

No
Yes

If you answered Yes to any of the above or have a condition not listed, please explain and list medications:

Patient Signature

Date

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Name

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