Patient History Form 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* Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Last Suffix Eye HistoryDate of last exam:By whom?Do you wear Contact Lenses?*YesNoWhich brand/type?Reason for today's visit, please list concerns:Medical HistoryName of medical doctor:Phone#:Date of last visit:Are you pregnant?YesNoHeight:Weight:Do you smoke?Do you smoke >NoYesFormer smokerAmount/how long?Do you drink alcohol?Do you drink alcohol >NoYesHow often?Do you use drugs?Do you use drugs >NoYesType/how often?Please list current medications/dosage:Medical Allergies:Do you have (or are being treated for) any of the following? Headaches/Migraines Seizures Psychiatric Disorder Emphysema Asthma Macular Degeneration HIV High Blood Pressure Loss of Vision High Cholesterol Joint/Muscle Pain Thyroid Disorder Immune Disorder Hepatitis Diabetes Type 1 Diabetes Type 2 Double Vision Sinus Congestion Cataracts Anemia Bleeding Disorder Heart Disease Flashes/Floaters Rheumatoid Arthritis Glaucoma Cancer Other Type of cancer:Other medical condition:Any Past eye surgeries/injuries? Which eye?Past surgeries/injuries?Diabetic Patients: Last A1c:Last checked blood sugar? WhenFamily HistoryPlease mark any family history including parents, grandparents, siblings, children and specify relationship:Cancer Mother Father Sister Brother Gr. Mother Gr. Father Daughter Son Aunt Uncle Cataracts Mother Father Sister Brother Gr. Mother Gr. Father Daughter Son Aunt Uncle Blindness Mother Father Sister Brother Gr. Mother Gr. Father Daughter Son Aunt Uncle Cause of blindness:Macular Degeneration Mother Father Sister Brother Gr. Mother Gr. Father Daughter Son Aunt Uncle Retinal Disease Mother Father Sister Brother Gr. Mother Gr. Father Daughter Son Aunt Uncle Lupus Mother Father Sister Brother Gr. Mother Gr. Father Daughter Son Aunt Uncle Heart Disease Mother Father Sister Brother Gr. Mother Gr. Father Daughter Son Aunt Uncle Kidney Disease Mother Father Sister Brother Gr. Mother Gr. Father Daughter Son Aunt Uncle Diabetes Mother Father Sister Brother Gr. Mother Gr. Father Daughter Son Aunt Uncle High Blood Pressure Mother Father Sister Brother Gr. Mother Gr. Father Daughter Son Aunt Uncle High Cholesterol Mother Father Sister Brother Gr. Mother Gr. Father Daughter Son Aunt Uncle CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.