Name
*
First Name
Middle Initial
Last Name
Suffix
Date
*
-
Month
-
Day
Year
Date
Primary Care Doctor
*
Dr.'s Phone
*
List all medications & dosage (milligrams) taken daily:
*
List any medication allergies and your reaction
*
Are you allergic to Latex?
*
Yes
No
Are you allergic to Iodine or Shellfish?
*
Yes
No
Are you allergic to Flurescein Dye?
*
Yes
No
Medical History
Self
Mother
Maternal Grandma
Maternal Grandpa
Father
Paternal Grandma
Paternal Grandpa
Glaucoma
Diabetic Retinopathy
Migraines
Retinal Detachment
Strabismus
Dry Eye
Cataracts
LASIK
Blindness
Corneal Transplant
Arthritis
Blindness
Cataracts
Macular Degeneration
Arthritis
Cancer
Diabetes
Heart Attacks
High Blood Pressure
Kidney Disease
Lupus
Sjogrens Syndrome
Stroke
Thyroid Disease
Tuberculosis
Patient Signature or Responsible Party if a Minor
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: