Medical History Online Form Name* First Last Date Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Guardian (if applicable)Phone*Cell PhoneEmail* OccupationDate of Birth Date Format: MM slash DD slash YYYY Last Eye Exam Date Format: MM slash DD slash YYYY Do you have vision insuranceYesNoinsurance carrierDo you have health insurance?YesNoinsurance carrierDo you have medicare?YesNo Primary Care PhysicianMedical HistoryList medications you take (including oral contraceptives, aspirin, over-the-counter medications, and home remedies) Check any of the following that you have had age-related macular degeneration inflammatory disorder cataract strabismus keratoconus amblyopia glaucoma suspect glaucoma surgery retinal degeneration/hole/detachment patching eye injury Are you pregnant and/or nursing?YesNo Do you wear glasses?YesNo how old is your present pair of lenses?Do you wear contact lenses?YesNo what brand?Type of contact lensesRigidSoftExtended Wear Are they comfortable?YesNo Family History Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditionsDisease/ConditionThyroid DiseaseYesNoNot sureRelationshipDiabetesYesNoNot sureRelationshipHypertensionYesNoNot sureRelationshipCancerYesNoNot sureRelationshipStrabismusYesNoNot sureRelationshipCataractYesNoNot sureRelationshipGlaucoma SuspectYesNoNot sureRelationshipAmblyopiaYesNoNot sureRelationshipSevere MyopiaYesNoNot sureRelationshipMacular DegenerationYesNoNot sureRelationshipRetinal Detachment/DiseaseYesNoNot sureRelationshipGlaucomaYesNoNot sureRelationshipSevere HyperopiaYesNoNot sureRelationshipOtherRelationshipSocial History This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer. Yes, I prefer to discuss my Social History information directly with the doctor.Do you drive?YesNodo you have visual difficulty when driving?YesNoplease describeDo you use tobacco products?YesNotype/amount/how longAre you aFormer SmokerCurrent Occasional SmokerCurrent Everyday Smoker Do you drink alcohol?YesNotype/amount/how longDo you use illegal drugs?YesNotype/amount/how longReview of SystemsDo you currently, or have you ever had, any problems in the following areasEyes Itching Diplopia Burning Mattering Loss of Vision Photophobia Red Floaters Loss of Sharpness Flashes Tearing Other Please specifyConstitutional Developmental Disorders Cancer Fatigue Syndrome Other Please specifyEar, Nose, Mouth, Throat Sinusitis Dry Mouth Hearing Loss Laryngitis Other Please specifyNeurological Epilepsy Multiple Seizures Tumor Cerebral Palsy Stroke/CVA Migraine Other Please specifyPsychiatric Depression Bipolar Anxiety Attention Deficit Other Please specifyVascular/Cardiovascular Vascular Disease Stroke Heart Disease High Blood Pressure Congestive Heart Failure Other Please specifyRespiratory Cigarette Smoker Bronchitis COPD Emphysema Asthma Sleep Apnea Other Please specifyGastrointestinal Celiac Disease Crohn's Disease Ulcer Colitis Acid Reflux Other Please specifyGenitourinary Kidney Disease STD - Herpetic/Chlamydia Prostate Disease/Cancer Pregnant/Nursing Other Please specifyMusculoskeletal Arthritis Ankylosing Spondylitis Fibromyalgia Muscular Dystrophy Osteoarthritis Gout Other Please specifyIntegumentary Herpes Simplex/Cold Sores Herpes Zoster/Shingles Rosacea Psoriasis Eczema Other Please specifyEndocrine Diabetes Type II Thyroid Dysfunction Hormonal Dysfunction Diabetes Type I Other Please specifyHematologic/Lymphatic Large Volume Blood Loss Anemia Ulcer High Cholesterol Other Please specifyAllergic/Immunologic Environmental Allergies Lupus Rheumatoid Arthritis Drug Allergies Sjogren’s Syndrome Other what drug?Please specifyIf you answered yes to any of the above, or have a condition not listed, please explain
