Medical History Form Select Your DoctorPlease selectDr. RobertsDr. WicklundPatient StatusPlease selectNew PatientCurrent PatientNot a patientPatient InformationName* First Middle Last Date of Birth* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Phone* SSN (last 4 digits only!) Gender Female Male Other Marital StatusPlease selectSingleMarriedDivorcedWidowedLast Eye ExamPlease selectNot ApplicableDon't Know1 month ago2 months ago3 months ago6 months ago9 months ago1 year ago1.5 years ago2 years ago2.5 years ago3 years ago3.5 years agoExam Type WantedPlease selectCheck UpFor GlassesFor ContactsFor Glasses and ContactsLASIK ConsultationMedical ConsultationExam Follow UpContact Follow UpSurgical Follow UpNot SureDo you currently wear glasses? Yes No Type of glassesPlease selectDistanceNearBothMonoDo you currently wear contacts? Yes No Type of contactsPlease selectSoftRigidBothCRTDo you currently use Low Vision Aids? Yes No Type(s) of Low Vision Aids Used Medical HistoryDo you currently have or have you ever had any of the following Eye Surgeries Eye Infections Cataracts Diabetes Headaches Pain Lazy Eye Eye Turn In/Out Tracking Problems Eye Injuries Amblyopia Dry Eyes High Blood Pressure Light Sensitivity Glaucoma Macular Degeneration Reading Problems Other Please DescribeAre you currently taking prescription or non-prescription drugs? Yes No Please list all prescription and non-prescription drugsDo you currently have any allergies known or perceived? Yes No Please list all known or perceived allergiesDo you have a problem with any of these systems Allergic/Immunologic Blood/Lymph Ear/Nose/Throat Gastrointestinal Kidney Problems Nervous Respiratory Thyroid Problems Arthritis Cardiovascular/Heart Disease Endocrine Glands Integument/Skin Musculature Psychiatric Skeletal/Bones Other Please DescribeDo you use any of the follow substances Cigarettes Alcohol Other Substances Packs per dayPlease selectHalf Pack1 pack1.5 packs2 packs2.5 packs3 packsMore than 3 packsFrequencyPlease selectSocial DrinkerOccasionally1 drink a day2 drinks a day3 drinks a day5 drinks a dayMore than 5 drinks a day1 drink a month2 drinks a month3 drinks a month4 drinks a month5 drinks a monthSubstancesPlease selectPrescribed SubstancesUn-Prescribed SubstancesFamily Eye HistoryHas anyone in the patient's family (blood relative) had any of the following? Cataracts Cornea Disease Diabetes Glaucoma Lazy Eye Macular Degeneration Retinal Disease High Blood Pressure Other Eye Disorders If Other, please explain:Your Surgical HistoryList any type of surgery and dates of surgeryOccupationIf applicable, what type of work do you do?HobbiesList any hobbies or sports you participate inVision Correction PreferencesPlease check all boxes that interest youLaser Vision Correction Laser vision correction LASIK with the new Wavefront® technology Contact Lenses Contacts that are comfortable ALL day long Disposable Contact Lenses CRT (Corneal Refractive Therapy) a non-surgical alternative to LASIK Contact Lenses to replace glasses Contact lenses that I can sleep in, wake up, and see. (a non-surgical alternative to LASIK) Contact lenses that require no care, to be worn for specific occasions Contact Lenses that correct astigmatism Contact Lenses that change eye color. (Even without prescription) Bifocal Contact Lenses Eyeglasses Extra thin and light eyeglass lenses Anti-reflective (Glare-Free) lenses. Reduce eyestrain. Great for night vision & computers Designer frames Frames that weigh less than a feather Invisible bifocal (No-Line progressives) Lenses that auto-adjust to comfortable shades of color, based on the light (In/Out door) Cosmetic tinted lenses - also tones down harsh indoor light for those who are light sensitive Specialty Glasses - Sports Frames, Snorkel/Scuba masks, swim, ski Motorcycle, Etc. Do you have any additional information you'd like to provide?EmailThis field is for validation purposes and should be left unchanged.
