Medical History w/ COVID ?

Name *

First Name Last Name
Date of Birth: *

Month Day Year
Date
Date: *

Month Day Year
Date
COVID-19 screening Questions

In the last two weeks have you:
Check all that apply *

Have you RECENTLY travelled out of the state? I have NOT had any COVID-19 symptoms or been exposed to anyone with symptoms. Fever Trouble breathing I have tested positive for COVID-19 I have been around someone with COVID-19 symptoms and or who has tested positive for COVID-19.
Note: Patient with COVID-19 symptoms or recent exposure will be asked to reschedule.
Reason for visit?

Routine exam Routine exam, with contacts
If using vision insurance do you plan to apply it towards (check all that apply)

Eyelgasses Contact lens
Eye Symptoms
Do you have blurry vision?

Yes without my glasses Yes with my glasses No I have no issues with my glasses
Check any that apply

Eyestrain (list when in other below) Double vision (describe type below, vertical, horizontal during what task)
Do you consent to being dilated at your exam? *

Yes, I would like to have dilation. No, I do not wish to have dilation. (Waiver will be sent)
If you are not a current contact lens wearer do you want to talk to the doctor about contacts?

Yes No

Family Medical and Eye History
Family Medical and Eye history

Parents, and siblings with conditions below specify who and condition when appropriate.
Cancer
Diabetes type 2
Diabetes type 1
High blood pressure
High cholesterol
Hyperthyroid
Hypothyroid
Macular degeneration
Cataracts
Glaucoma
Retina detachment
Other eye or health condition
Thank you for completing your medical history form.

We look forward to seeing you soon.

When you arrive PARK & CALL.

Don't forget your mask.
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

COVID-19 screening Questions