Medical History Form Thank you for completing this form. This information will assist the doctors and team members in providing quality care. This form contains confidential information and is delivered to your doctor through a secure Internet connection.Patient InformationName* First Middle Last Today's Date* *HeightWeightDate of Birth* MM slash DD slash YYYY Gender* Female Male Are you pregnant or nursing? No Yes Medical HistoryDo you currently suffer from any Systemtic Issues?Check all that apply. Anemia Bleeding Disorders Sickle Cell Clotting Disorders Arthritis Diabetes Hyper- or Hypo- Thyroid Autoimmune Disorders Fibromyalgia Systemic Connective Tissue Diseases Dermatitis/Eczema Do you currently suffer from any Lung Issues?Check all that apply. Asthma Emphysema Bronchitis Pneumonia Do you currently suffer from Vascular Issues?Check all that apply. Congestive Heart Failure Heart Attack Heart Disease High Cholesterol High Blood Pressure Stroke Pacemaker Defibrillator Do you currently suffer from Other Issues?Check all that apply. Hepatitis HIV/AIDS Seizures Herpes Do you suffer from issues not listed?Please list any other medical issues below. Are you currently taking long-term corticosteroids? Yes No Family HistoryNote any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions.Do any family members have/had Systemtic issues?Check all that apply. Anemia Bleeding Disorders Sickle Cell Clotting Disorders Arthritis Diabetes Hyper- or Hypo- Thyroid Autoimmune Disorders Fibromyalgia Systemic Connective Tissue Diseases Dermatitis/Eczema Do any family members have/had Lung Issues?Check all that apply. Asthma Emphysema Bronchitis Pneumonia Do any family members have/had Vascular Issues?Check all that apply. Congestive Heart Failure Heart Attack Heart Disease High Cholesterol High Blood Pressure Stroke Pacemaker Defibrillator Do any family members have/had Other Issues?Check all that apply. Hepatitis HIV/AIDS Seizures Herpes Do any family members have/had issues not listed?Please list any other medical issues below. Ocular HistoryDo you wear: Glasses Contact Lenses Over the Counter Reading Glasses Do you suffer from any Ocular Issues? Keratoconus Amblyopia/Strabismus Blindness Cataract Glaucoma Macular Degeneration Retinal Detachment Eye Injury/Trauma PAST RK, PRK, or LASIK Eye or Lid surgery Dry Eye Syndrome Eye Allergies Do any family members have/had Ocular Issues?Note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. Keratoconus Amblyopia/Strabismus Blindness Cataract Glaucoma Macular Degeneration Retinal Detachment Eye Injury/Trauma PAST RK, PRK, or LASIK Eye or Lid surgery Dry Eye Syndrome Eye Allergies Surgical HistoryPlease list all prior eye surgeriesSurgery ProcedureYear of Occurrence Please list all prior major surgeriesSurgery ProcedureYear of Occurrence MedicationsPlease list all medications you are currently taking.Drug NameStrengthFrequency This includes over-the-counter medicines or home remediesAllergiesPlease list all allergies to medication, food or other items.AllergyReaction If you have no allergies, write NONE.Are you sensitive to Iodine/Tape/Latex?* Yes No If yes, Did your reaction result in:Check all that apply. Skin rash or hives Wheezing or trouble breathing Hay fever or runny nose Social HistoryThis information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer. Please check the box below of you prefer to discuss with the doctor instead.I prefer to discuss my Social History information directly with my doctor. Yes Do you use/have used tobacco products? No Yes If Yes, list type/amount/how long:Do you drink alcohol? No Yes If Yes, list type/amount/how long:Do you use caffeine? No Yes If Yes, list type/amount/how long:Do you use illegal drugs? No Yes If Yes, list type/amount/how long:Patient Signature Date MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
