Medical History

Medical History

In an effort to make your appointment more efficient and limit the time you will need to be in our office, please enter the information below. If a section doesn’t apply to you, please write “none”. The form below is HIPAA compliant & encrypted to protect your privacy.

First Name*
Last Name*
Phone*
Email
DOB*
MM slash DD slash YYYY
What is the reason for your appointment?
Do you have any vision problems? If so, please explain in detail including which eye(s) and how long you have had that problem.
Do you have any eye pain, itching, redness, or tearing? If so, please explain in detail including which eye(s) and how long you have had that problem.
Are you using any eye drops? If so, which ones, what do you use them for, which eye(s), how many times per day, and for how long have you been using them?
Please list any known eye diseases.
Please list any eye surgeries you have had.
Please list any eye diseases that others in your family have and state who the person is in relation to you.
Please list all medical problems you have.
Please list all medications you take, including dose and how often you take them.
Please list any previous major surgeries and approximately when you had them.
Please list any family history of medical problems, especially if any history of diabetes or high blood pressure.
Do you or have you ever smoked? If so, please write how much you smoke or used to smoke and what years. Please also list any use of alcohol or drugs.
Do you have diabetes? If so, what year were you first diagnosed? Please write your latest A1C level and/or your average blood sugars.
Please list any allergies you have to medications and/or foods and what your reaction is. If you don't have any allergies, please write "none."

Tired of Blurry Vision?

Tired of Glasses & Contacts?

Learn About Financing
and Flex Spending

Contact US

Medical History

Tired of Blurry Vision?

Tired of Glasses & Contacts?

Learn About Financingand Flex Spending

Contact US

Learn About Financing
and Flex Spending