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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin 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 Social Security Number (last 4 digits only!) Race/Ethnicity Preferred Language Gender Female Male 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) 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 TakenList 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 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 Do you drive? No Yes If Yes, do you have visual difficulty when driving? No Yes If Yes, please describe:Do you use tobacco products? No Yes If Yes, list type/amount/how long:Do you drink alcohol? No Yes If Yes, list type/amount/how long:Do you use illegal drugs? No Yes If Yes, list type/amount/how long:Have you ever been exposed to or infected with: Gonorrhea Hepatitis HIV Syphillis REVIEW OF SYSTEMSDo you currently or have you ever had any problems in the following areas?ConstitutionalFever, Weight Loss/Gain No Yes Integumentary (Skin) No Yes 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 Ears, Nose, Mouth, ThroatSinus Congestion No Yes Runny Nose No Yes Post-Nasal Drip No Yes Chronic Cough No Yes Dry Thoat/Mouth No Yes Allergies/Hay Fever No Yes RespiratoryAsthma No Yes Chronic Bronchitis No Yes Emphysema No Yes Vascular/CardiovascularDiabetes No Yes Heart Pain No Yes High Blood Pressure No Yes Vascular Disease No Yes GastrointestinalDiarrhea No Yes Constipation No Yes GenitourinaryGenitals/Kidney/Bladder No Yes Bones/Joints/MusclesRheumatoid Arthritis No Yes Muscle Pain No Yes Joint Pain No Yes Lymphatic/HematologicAnemia No Yes Bleeding Problems No Yes Allergic/ImmunologicAllergic/Immunologic No Yes PsychiatricPsychiatric 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 PhoneThis field is for validation purposes and should be left unchanged.
*Saturdays by appointment only.