Medical History Online Form Name* First Last HiddenDate 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Guardian (if applicable) Phone*Cell PhoneEmail* Occupation Date of Birth MM slash DD slash YYYY Last Eye Exam MM slash DD slash YYYY Do you have vision insurance Yes No insurance carrier Do you have health insurance? Yes No insurance carrier Do you have medicare? Yes No Primary Care Physician Medical 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? Yes No Do you wear glasses? Yes No how old is your present pair of lenses? Do you wear contact lenses? Yes No what brand? Type of contact lenses Rigid Soft Extended Wear Are they comfortable? Yes No Family History Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditionsDisease/ConditionThyroid Disease Yes No Not sure Relationship Diabetes Yes No Not sure Relationship Hypertension Yes No Not sure Relationship Cancer Yes No Not sure Relationship Strabismus Yes No Not sure Relationship Cataract Yes No Not sure Relationship Glaucoma Suspect Yes No Not sure Relationship Amblyopia Yes No Not sure Relationship Severe Myopia Yes No Not sure Relationship Macular Degeneration Yes No Not sure Relationship Retinal Detachment/Disease Yes No Not sure Relationship Glaucoma Yes No Not sure Relationship Severe Hyperopia Yes No Not sure Relationship Other Relationship Social 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? Yes No do you have visual difficulty when driving? Yes No please describe Do you use tobacco products? Yes No type/amount/how long Are you a Former Smoker Current Occasional Smoker Current Everyday Smoker Do you drink alcohol? Yes No type/amount/how long Do you use illegal drugs? Yes No type/amount/how long Review 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 specify Constitutional Developmental Disorders Cancer Fatigue Syndrome Other Please specify Ear, Nose, Mouth, Throat Sinusitis Dry Mouth Hearing Loss Laryngitis Other Please specify Neurological Epilepsy Multiple Seizures Tumor Cerebral Palsy Stroke/CVA Migraine Other Please specify Psychiatric Depression Bipolar Anxiety Attention Deficit Other Please specify Vascular/Cardiovascular Vascular Disease Stroke Heart Disease High Blood Pressure Congestive Heart Failure Other Please specify Respiratory Cigarette Smoker Bronchitis COPD Emphysema Asthma Sleep Apnea Other Please specify Gastrointestinal Celiac Disease Crohn's Disease Ulcer Colitis Acid Reflux Other Please specify Genitourinary Kidney Disease STD - Herpetic/Chlamydia Prostate Disease/Cancer Pregnant/Nursing Other Please specify Musculoskeletal Arthritis Ankylosing Spondylitis Fibromyalgia Muscular Dystrophy Osteoarthritis Gout Other Please specify Integumentary Herpes Simplex/Cold Sores Herpes Zoster/Shingles Rosacea Psoriasis Eczema Other Please specify Endocrine Diabetes Type II Thyroid Dysfunction Hormonal Dysfunction Diabetes Type I Other Please specify Hematologic/Lymphatic Large Volume Blood Loss Anemia Ulcer High Cholesterol Other Please specify Allergic/Immunologic Environmental Allergies Lupus Rheumatoid Arthritis Drug Allergies Sjogren’s Syndrome Other what drug? Please specify If you answered yes to any of the above, or have a condition not listed, please explain