Medical History Form

Select Your Doctor
Patient Status
Patient Information
Name*
First Middle Last
Date of Birth*
Address*
Street Address Address Line 2 City State ZIP Code
Email
Phone*
SSN (last 4 digits only!)
Gender
- Female
- Male
- Other
Marital Status
Last Eye Exam
Exam Type Wanted
Do you currently wear glasses?
- Yes
- No
Type of glasses
Do you currently wear contacts?
- Yes
- No
Type of contacts
Do you currently use Low Vision Aids?
- Yes
- No
Type(s) of Low Vision Aids Used
Medical History
Do 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 Describe
Are you currently taking prescription or non-prescription drugs?
- Yes
- No
Please list all prescription and non-prescription drugs
Do you currently have any allergies known or perceived?
- Yes
- No
Please list all known or perceived allergies
Do 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 Describe
Do you use any of the follow substances
- Cigarettes
- Alcohol
- Other Substances
Packs per day
Frequency
Substances
Family Eye History
Has 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 History
List any type of surgery and dates of surgery
Occupation
If applicable, what type of work do you do?
Hobbies
List any hobbies or sports you participate in
Vision Correction Preferences
Please check all boxes that interest you
Laser 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?
Email
This field is for validation purposes and should be left unchanged.

Patient Information

Medical History

Family Eye History

Your Surgical History

Occupation

Hobbies

Vision Correction Preferences

20/20 Visions