Medical History Form

Medical History Form
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Occupation
Hobbies
Primary Care Physician
Personal History: Check the conditions that apply to you:*

AsthmaCOPDCancerHeart Disease.DiabetesThyroid DiseaseHypertensionHigh CholesterolStrokePsychiatric DisorderEpilepsyOsteoarthiritisRheumatoid ArthiritisNeck or Back PainGlaucomaMacular DegenerationRetinal DetachmentChoroidal Nevus (Eye Freckle)StrabismusCataractAmblyopia/Lazy EyeMyopiaAstigmatismHypermetropiaKeratoconusDry Eye SyndromeEye SurgeryEye InjuryNoneSpine or disc conditionsOther
Surgical History (List out your past surgeries for both general health and eyes):*
Family History: Check the conditions that apply to your blood relatives:*

AsthmaCOPDCancerHeart Disease.DiabetesThyroid DiseaseHypertensionHigh CholesterolStrokePsychiatric DisorderEpilepsyGlaucomaMacular DegenerationRetinal DetachmentChoroidal Nevus (Eye Freckle)StrabismusCataractAmblyopia/Lazy EyeMyopiaAstigmatismHypermetropiaKeratoconusDry Eye SyndromeEye SurgeryEye InjuryNoneOther
Check the eye symptoms that you're currently experiencing:*

Blurred VisionItchingDouble VisionBurningLoss of VisionPhotophobiaRednessFloatersFlashes of LightTearingGrittinessHeadacheNoneOther_______________________________________
Check the medical symptoms that you're currently experiencing:*

Chest painWeight gainWeight lossFatigueDepressionAnxietySinus CongestionDry MouthHearing LossSore ThroatCoughTrouble SleepingSeizuresDizzinessVertigoFainting SpellsScalp TendernessTrouble ChewingStomach PainMuscle PainJoint PainNeck or Back PainAllergiesIncreased ThirstIncreased UrinationDifficulty BreathingTension HeadachesMigraine HeadachesNoneOther
Current medications and eyedrops:*
Allergies to medications:*
Do you currently use tobacco?*
Are you currently pregnant or Breastfeeding ?*
Do you have history of using tobacco?*
Do you use or do you have history of using illegal drugs?*
How often do you consume alcohol?*

1-2 drinks dailyAbove averageAlcohol dependenceSocial UseNever
Should be Empty: