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 InformationName* First Middle Last Today's Date* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Number*Please provide a telephone number, with area code, so we can contact you. Cell PhoneWork PhoneEmail AddressPlease provide your email address. Employer Occupation Date of Birth* MM slash DD slash YYYY 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 HistoryDo 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 TakenCheck any of the following that you have had: Crossed Eyes Lazy Eye Drooping Eyelid Prominent Eyes Cataracts Glaucoma Iritis/Uveitis Macular Degeneration Retinal Disease of Detachment Eye Infections Eye Injury Corneal Problems Other Eye Disorders 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 HistoryNote 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 Other, please explain:If Yes to any of the above, please explain:Social HistoryThis 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 SYSTEMSDo you currently or have you ever had any problems in the following areas?NeurologicalHeadaches No Yes Migraines No Yes Seizures No Yes EyesLoss 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 EndocrineThyroid/Other Glands No Yes Elevated Cholesterol No Yes Cancer No Yes Vascular/CardiovascularDiabetes No Yes Heart Pain No Yes High Blood Pressure No Yes Vascular Disease No Yes Bones/Joints/MusclesRheumatoid Arthritis No Yes Lymphatic/HematologicBleeding 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 MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.