Advanced EyecareMedical History Questionnaire
Please fill out all information to the best of your ability!We apologize for this inconvenience, but due to changes in computer systemsand insurance company requirements, we cannot efficiently care for you without this data.
Family History (parents, grandparents, siblings, children; living or deceased)
Relationship To You
Otherwise, please answer the following questions:
Review of Systems Have you ever been SEEN BY A DOCTOR for any of the following conditions??
Ear, Nose, Mouth, Throat
Vascular / Cardiovascular
Bones/ Joints/ Muscles
Lymphatic / Hematologic
If you answered YES to any of the above or have a condition not listed, please explain to Doctor Palozej.
I understand that the information that I have given today is correct to the best of my knowledge. I also know that this information will be held in the strictest confidence and that it is MY responsibility to inform this office of any changes. I authorize the doctor's optometric staff to perform any optometric service with my consent.