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Health History Form

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New Patients: Once you have filled out this form, please be sure to also fill out our New Patient Form.

Required fields are marked with an asterisk (*).

Patient Information



Patient name: (*)

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Birthdate: (*)

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E-Mail Address:

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Have you visited our office before?

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Current Occupation:

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Computer used?:

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If yes, how many hours/day?

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Do you drive?

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Do you have any problems driving?

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If yes, please explain:

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Do you have problems with night vision?

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Do you wear glasses?

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If yes, how old are they?

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Do you wear contact lenses?

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If yes, what brand are they?

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If you have your contact lenses inserted, how old are they?

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Are you interested in trying contact lenses if you do not wear them?

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Do you wear sunglasses?

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If yes, how old are they?

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Chief Complaint:

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Medical History



Family Doctor Name:

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Family Doctor Phone Number:

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Date of last physical examination:

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Date of last eye exam:

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Were you dilated?

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Height:

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Weight:

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Please list any medications, dosages, frequency and why you take them:

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List all major illnesses, injuries, or surgeries:

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Do you have any drug allergies?

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If yes, please list:

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LASIK Surgery:

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Date:

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Cataract Surgery:

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Date:

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Retinal Surgery:

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Date:

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Eye History

Please check all of the following conditions you experience.



























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Do you have or have a family history of:












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What are your relationships to the family members with the above conditions?

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Review of Systems:

Do you currently, or have you or any family member ever had any problems in the following areas?

Constitutional:


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Integumentary:


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Neurological:




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Endocrine:


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Ears/Nose/Throat/Mouth:







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Respiratory:




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Vascular/Cardiovascular:





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Gastrointestinal:



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Genitourinary:


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Bones/Joints/Muscles:




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Lymphatic/Hematologic:

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Allergic/Immunologic:

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Psychiatric:

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If you answered any of the above or have a condition not listed, please explain below:

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Social History



Do you drink alcohol?

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If so, how much?

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Tobacco Use?

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Stopped Smoking?

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