• Jolly Good Eye Care, PLLC

  • Patient Information and Medical History Form and Consent

  •  - -
    Pick a Date
  • Please provide BOTH your Vision and Medical Insurance to  better assist you.

  •  - -
    Pick a Date
  • General Medical History

  •  
  • Review of Systems: Please list any problems you are having anywhere, from head to toe.

  • General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain) 

  • Ear, Nose, Throat (e.g., sinus/nasal congestion, nose bleeds, dry mouth/throat, sleep apnea, hearing problems)

  • Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs)

  • Respiratory (e.g., chronic cough, shortness of breath, wheezing)

  • Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, discharge, menstrual changes, impotence)

  • Gastrointestinal (e.g., constipation, diarrhea, gastric reflux (GERD), jaundice, nausea, vomiting)

  • Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination)

  • Muscles, Bones, Joints (e.g., pain, stiffness, swelling, weakness, limited movements)

  • Skin (e.g., dry, itchy, flaky, rash, growths, bumps, redness, discoloration)

  • Neurological (e.g., headaches, numbness/tingling, tremors, poor balance, dementia, speech problems)

  • Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive)

  • Blood/Lymph (e.g., anemia, bleeding gums, delayed clotting, unexplained bruising)

  • Allergy/Immune (e.g., swollen lymph nodes, itching, sneezing, runny nose/eyes) 

  • Ocular History

  •  
  • ***We at Jolly Good Eye Care are required by law to maintain the privacy of
    and provide individuals with the Notice of our legal duties and privacy
    practices with respect to protected health information, which can be viewed on our website. If you would like a copy of the Notice, please ask.***

  • Clear
  •  - -
    Pick a Date
  • Should be Empty: