Please complete the form below or click here to download a printable version. "*" indicates required fields Patient Name* Date of Birth* MM slash DD slash YYYY What is the reason for your upcoming visit to our office?Medical InformationCheck the medical conditions that apply to you and/or your family.Allergy/Immunologic(Allergies, Sinusitis) Self Family Please explain.*Cardiovascular(Heart, Blood Pressure, Stroke) Self Family Please explain.*Constitutional(Fatigue, Nausea, Thirst) Self Family Please explain.*Endocrine(Cholesterol, Diabates, Thyroid) Self Family Please explain.*Ears/Nose/Throat/Mouth(Dry Mouth) Self Family Please explain.*Gastrointestinal(Colitis, Ulcer, Chron’s) Self Family Please explain.*Genitourinary(Kidney, Bladder, Syphilis, STD) Self Family Please explain.*Hematologic/Lymphatic(Anemia, Breast Carcinoma) Self Family Please explain.*Integumentary/Skin(Rosacea, Lupus, Psoriasis) Self Family Please explain.*Musculoskeletal(Skeletal, Arthritis, Myasthenia Gravis) Self Family Please explain.*Neurologic(Bell’s Palsy, Brain Tumor, Headache) Self Family Please explain.*Psychiatric(ADD, Learning Disability, Bi-Polar) Self Family Please explain.*Respiratory(Asthma, COPD, Emphysema) Self Family Please explain.*Developmental(Premature, Autism, Delayed) Self Family Please explain.*List other medical problems:Who is your primary physician? Other Doctors you visit:Date of last physical examination If you were referred here by your doctor, give the reason: Are you allergic to any medicines? List: Do You Use Tobacco? Yes No Do you use Alcohol? Yes No Do you use Other Substances? Yes No Height Weight Do you have a history of STD? Yes No Do you have a history of blood transfusions? Yes No Surgeries (List type and date)Eye & Vision HistoryCheck the eye conditions that apply to you and/or your family.Amblyopia (lazy eye) Self Family Please explain.*Blindness Self Family Please explain.*Light Sensitivity Self Family Please explain.*Cataracts Self Family Please explain.*Color Blindness Self Family Please explain.*Diabetic Retinopathy Self Family Please explain.*Eye Pain Self Family Please explain.*Dry Eyes Self Family Please explain.*Eye Infections Self Family Please explain.*Head Trauma Self Family Please explain.*Eyestrain Self Family Please explain.*Glaucoma Self Family Please explain.*Flashing Lights Self Family Please explain.*Red Eyes Self Family Please explain.*Floaters/Spots in Vision Self Family Please explain.*Eye Injury Self Family Please explain.*Vision comes and goes Self Family Please explain.*Macular Degeneration Self Family Please explain.*Retinal Detachment Self Family Please explain.*Strabismus (crossed eye) Self Family Please explain.*Blind Spot in Vision Self Family Please explain.*Have you had eye surgery? Yes No Please explain.*Any eye problems at this time? Please explain. Do you take any medications including eye drops? List: 65841
