Medical History Form Select Your DoctorPlease selectDr. RobertsDr. WicklundPatient StatusPlease selectNew PatientCurrent PatientNot a patinetFirst Name*Last Name*Date of Birth* MM DD YYYY 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* PhoneSSNGender*MaleFemaleOtherMarital StatusSingleMarriedDivorcedWidowedLast Eye ExamNeverNot 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 WantedCheck UpFor GlassesFor Contact LensesFor Glasses and ContactsLASIK ConsultationMedical ConsultationExam Follow UpContact Follow UpSurgical Follow UpNot SureDo you currently wear glasses?YesNoType of glassesDistanceNearBothMonoDo you currently wear contacts?YesNoType of contactsSoftRigidBothCRTDo you currently use Low Vision Aids?YesNoType(s) of Low Vision Aids UsedDo you currently have or have you ever had any of the following Eye Surgeries Eye Injuries Eye Infections Amblyopia Cataracts Dry Eyes Diabetes High Blood Pressure Headaches Light Sensitivity Pain Glaucoma Lazy Eye Macular Degeneration Eye Turn In / Out Reading Problems Tracking Problems Other Are you currently taking prescription or non-prescription drugs?YesNoPlease list all prescription and non-prescription drugsDo you currently have any allergies known or perceived?YesNoPlease list all known or perceived allergiesDo you have a problem with any of these systems Allergic / Immunologic Arthritis Blood / Lymph Cardiovascular Heart Disease Ear / Nose / Throat Endocrine Glands Gastrointestinal Integument Skin Kidney Problems Musculature Nervous Psychiatric Respiratory Skeletal Bones Thyroid Problems 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 week2 drinks a week3 drinks a week4 drinks a week5 drinks a weekMore than 5 drinks a week1 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 Retina Disease High Blood Pressure Other Eye Disorders 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. Sunglasses UV (Ultra-Violet) light protection Polaroid lenses -considerably reduces sun & reflective glare, & eliminates horizontal reflections Sunglasses to wear with Contact Lenses Children's Vision I need to know at what age should children have their first eye exam I need to know at what age can children wear Contact Lenses Protective eyeglasses for sports I need to know the difference between Screenings & eye examinations Do you have any additional information you'd like to provide?NameThis field is for validation purposes and should be left unchanged.