Patient Medical History Form

General Patient Information
Patient Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Patient Birth Date*

MonthDayYear
Patient Gender*
Patient E-Mail*
example@example.com
Occupation
Reason for Visit*
Patient Medical History
Eye History: List any eye surgeries or significant eye history
If you wear contacts, what is the brand and parameters (BC and power)
List any Family Eye History - 1st degree relatives: mom, dad, sister, brother etc.
List Family Medical History conditions
Please list any drug allergies
Have you ever had any ailments in these categories? (Please check all that apply)

Respiratory (ie Asthma, Bronchitis, Emphysema, Chronic Obstruction, Sleep Apnea,Ear Nose Throat: Hearing Loss, Sinusitis, Dry Mouth, LaryngitisNeuro: Multiple sclerosis, Epilepsy, Cerebral Palsy, Tumor, Stroke,CVA, Migraine, AutismPsych: Depression, Anxiety,Attention Deficit,Bipolar,Emotional DisorderotherCardiovascular: Hypertension, High cholesterol,Stroke, CVA,Heart disease, vascular disease,Congestive Heart failure, otherGI: Crohns,Colitis, ulcer,acid reflux,Celiac disease,GU:Kidney disease, Prostate disease,STD, Pregnant, Nursing, herpes,ChlamydiaMusc/Skel:Arthritis, Osteoarthritis, Fibromyalgia,Muscula Dystrophy,Ankylosing Spondylitis, Osteoporosis, Gout,Skin:Eczema, Rosacea, Psoriasis, Herpes Simplus, Herpes Zoster, ShinglesEndo: Type 2 Diabetes, Type 1 Diabetes,Thyroid Dysfunction, Hormonal DysfunctionHem/Lymph: Anema, Large blood volume loss,ulcer, HypercholesteremiaAllergies/Immun: Drug allergies, environmental allergies, food allergies, rheumatoid arthritis, Lupus,Sjogrens syndrome
If you have checked any boxes above, please list your condition(s):
Please list your Current Medications
Healthy & Unhealthy Habits
Alcohol Consumption

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Recreational Drugs

YesNo
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History
Should be Empty:

General Patient Information

Patient Medical History

Healthy & Unhealthy Habits