Medical History Record For faster service, please complete the following form prior to arriving at our office.Appointment Date Patient’s Name First Middle Last Birth Date GenderMaleFemaleAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home PhoneWork PhoneEmployerOccupationEmergency ContactPhone NumberDate of Last Eye Exam Name of Previous Eye DoctorPersonal Medical InformationDo you have problems with any of these systems?If Yes, please check box. Gastrointestinal Nervous System Mental Ear/Nose/Throat Genitourinary Endocrine (Glands) Cardiovascular Musculoskeletal Blood/Lymph Respiratory Skin Allergic/Immunologic Headaches Surgeries (what type& when)Are you in good health?YesNoAny allergic reactions to medications or other substances?YesNoIf yes, please listName of general physicianDo you smoke?YesNoIf yes how much?Do you drink alcohol?YesNoIf yes how much?Do you take medications?YesNoIf yes, Please list names & how oftenDo you use other substances?YesNoDo you have family history of any of the following? If Yes, please check box. Diabetes Glaucoma High blood pressure Macular Degen Retinal Detachmt Cataracts Please explain any boxes you have checkedDo you have any of the following? If Yes, please check box. Dry Eyes Eye Surgeries Wear Glasses Blurred Vision Eye Injuries Wear Contacts Any eye problems at this time? Please explainAre you interested in laser vision correction?YesNoPlease sign below that you have reviewed all information above and it is correct to the best of your knowledge.SignatureDate
