Medical History w/ COVID ?

Name *

First Name Last Name
Date of Birth: *

Month Day Year
Date
Date: *

Month Day Year
Date
PLEASE NOTE:

Per the department of health guidelines our healthcare clinic still requires masks to be worn at all times for ages 2 and older. If you have had any COVID symptoms, exposure to someone with COVID symptoms or have tested positive for COVID within in 2 weeks of your appointment we will need rescheduled your appointment.
COVID-19 screening Questions

In the last two weeks have you: (please answer for the patient if you are filling this form for someone else)
Check all that apply *

In the past 14 days I have had a fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting or diarrhea? I have travelled to areas with high COVID risk. I have tested positive for COVID-19 I have been around someone with COVID-19 symptoms and or with someone who has tested positive for COVID-19. I do NOT have any COVID-19 symptoms and have NOT had any exposure to anyone with these symptoms and have NOT tested positive for COVID-19 in the last 14 days.
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.
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PLEASE NOTE:

COVID-19 screening Questions

Eye Symptoms

Contact lens wearers

Medical History

Family Medical and Eye history