Patient History Form Please fill in the form below and submit. Please complete the information below and submit the form online or, if you prefer, print out the form after full or partial completion and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.Patient InformationName* First Middle Last Today's Date*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home Number*Please provide a telephone number, with area code, so we can contact you.Cell PhoneWork PhoneEmail AddressPlease provide your email address.EmployerOccupationDate of Birth* Social Security Number (last 4 digits only!)Please enter a value between 0000 and 9999.Race/EthnicityPreferred LanguageGenderFemaleMaleWho may we thank for referring you to our office?Date of Last Medical ExamName of Medical DoctorDoctor's Phone NumberDate of Last Eye ExamCurrent HeightCurrent WeightSpouse or Guardian (If Applicable)Medical HistoryDo you have any allergies to medications?NoYesIf Yes, list medication(s) and reaction below:List any medications you take including oral contraceptives, aspirin, OTC medicines, etc.:Include Name of Medication, Dosage, Frequency TakenList all major injuries, surgeries and/or hospitalizations you have had:Check any of the following that you have had: Crossed Eyes Lazy Eye Drooping Eyelid Prominent Eyes Cataracts Glaucoma Iritis/Uveitis Macular Degeneration Retinal Disease of Detachment Eye Infections Eye Injury Corneal Problems Other Eye Disorders If Other Eye Disorders, please explain:Are you pregnant or nursing?NoYesDo you wear glasses?NoYesIf Yes, how old is your present pair of lenses?Do you wear contact lenses?NoYesIf Yes, how old is your present pair of lenses?Type of Contact Lenses: Rigid Soft Extended Wear Other Are they comfortable?NoYesFamily HistoryNote any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.Disease/Condition Blindness Cataract Crossed Eyes Glaucoma Macular Degeneration Retinal Detachment or Disease Arthritis Cancer Diabetes Heart Disease High Blood Pressure Kidney Disease Lupus Thyroid Disease Other If Other, please explain:If Yes to any of the above, please explain:Social HistoryThis information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer. Please check the box below of you prefer to discuss with the doctor instead.I prefer to discuss my Social History information directly with my doctor. Yes Do you drive?NoYesIf Yes, do you have visual difficulty when driving?NoYesIf Yes, please describe:Do you use tobacco products?NoYesIf Yes, list type/amount/how long:Do you drink alcohol?NoYesIf Yes, list type/amount/how long:Do you use illegal drugs?NoYesIf Yes, list type/amount/how long:Have you ever been exposed to or infected with: Gonorrhea Hepatitis HIV Syphillis REVIEW OF SYSTEMSDo you currently or have you ever had any problems in the following areas?ConstitutionalFever, Weight Loss/GainNoYesIntegumentary (Skin)NoYesNeurologicalHeadachesNoYesMigrainesNoYesSeizuresNoYesEyesLoss of VisionNoYesBlurred VisionNoYesDistorted Vision/HalosNoYesLoss of Side VisionNoYesDouble VisionNoYesDrynessNoYesMucous DischargeNoYesRednessNoYesSandy or Gritty FeelingNoYesItchingNoYesBurningNoYesForeign Body SensationNoYesExcess Tearing/WateringNoYesGlare/Light SensitivityNoYesEye Pain or SorenessNoYesChronic Infection, Eye or LidNoYesSties or ChalazionNoYesFlashes/Floaters in VisionNoYesTired EyesNoYesEndocrineThyroid/Other GlandsNoYesElevated CholesterolNoYesCancerNoYesEars, Nose, Mouth, ThroatSinus CongestionNoYesRunny NoseNoYesPost-Nasal DripNoYesChronic CoughNoYesDry Thoat/MouthNoYesAllergies/Hay FeverNoYesRespiratoryAsthmaNoYesChronic BronchitisNoYesEmphysemaNoYesVascular/CardiovascularDiabetesNoYesHeart PainNoYesHigh Blood PressureNoYesVascular DiseaseNoYesGastrointestinalDiarrheaNoYesConstipationNoYesGenitourinaryGenitals/Kidney/BladderNoYesBones/Joints/MusclesRheumatoid ArthritisNoYesMuscle PainNoYesJoint PainNoYesLymphatic/HematologicAnemiaNoYesBleeding ProblemsNoYesAllergic/ImmunologicAllergic/ImmunologicNoYesPsychiatricPsychiatricNoYesIf you answered Yes to any of the above or have a condition not listed, please explain and list medications:Patient SignatureDate PhoneThis field is for validation purposes and should be left unchanged.