New Patient Medical History Form

Medical History Form - Entries
New Patient Medical History Form

Required
Name*
Date*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Phone*
Email*
example@example.com
Medical History
What brings you to the office today?
Please Check any Medical Conditions you may have:*

Diabetes Type 1Diabetes Type 2Thyroid DiseaseHypertensionCoronary Artery DiseaseHigh CholesterolRheumatological DieaseAIDS/HIVHeart DiseasePacemakerStentsCurently PregnantMigraine HeadacheLupusKidney DiseaseLiver DiseaseCancer- Type______________________AsthmaChemical DependencyStrokeSeizure disorderDepressionBack PainFever, chillsCoughOther
Have you been admitted to the hospital in the past two years?*

NoYes, if yes enter the reason below:
Reason for hospital admission:
List surgeries other than eye surgery:*
Please list any medicine you take including nonprescription medicines and vitamins. or type 'None"*
Please list allergies to Medications or type 'None'*
Do you smoke if yes # of years and #packs per day?*
How much alcohol do you drink per week?*
Please list any eye surgery including vision correction surgery or 'None"*
If you wear contacts please enter name brand, power right and left, and base curve (BC)
Eye History- Check all Conditions that apply to you:*

Distorted vision - HalosItchy eyesBurning eyesMacular degenerationRetinal diseaseStyeEye infectionNeed new glassesForeign body sensation in eyesLoss of visionNeed new contactsGlaucomaSandy feeling in eyesCrusty eyesTired eyesRedness in eyesFluctuating visionDiabetic eye examEyes sensitive to lightEyes water or tearEye pain which eye?Dry eyesDouble visionBlurred visionIrritation with contactsStrabismus or Lazy eyeFloaters which eye?_________Flashing lights which eye?________________Eyelid problem describe___________Other
Do you wear eyeglasses*

YesNo
If you wear glasses what type?

DistancePrescription Reading glassesProgressivesBifocalsSunglassesOTC Readers
Family History
Please check all that apply to your family members:*

CataractsGlaucomaMacular DegenerationDiabetesSjogren's DiseaseBlindnessStrokeNearsighted (myopia)Retinal DetachmentHypertensionCancerCardiac DiseasePsychiatric DisordersNone
Have you had a positive covid 19 test? Is so When? and have you been retested and the result was negative?*
Should be Empty:

New Patient Medical History Form

Medical History

Family History