New Patient Medical History Form-copy New Patient Medical History Form-2018 Please note: This form must be completed in full before you can submit it. If there is nothing to list, write “N/A” (not applicable). Gender Male Female Patient Name* First Last Birthdate* Month Day Year When was your last eye exam? Who did your eye exam? Do you wear glasses?* No Yes If yes, how old is your present pair of lenses? Do you wear Contact Lenses?* No Yes If yes, how old is your present pair of lenses? Are you interested in Contact Lenses?* No Yes Are you interested in Colored Contact Lenses?* No Yes Name of Medical Doctor Dr Phone # Dr Fax # List any medications you currently take, as well as eye drops: Do you have any allergies to any medications?* No Yes Explain: List any eye injuries or eye surgeries:iInclude which eye and date of occurrence(s)InjuryWhich eye?Date of occurrence Are you pregnant and/or nursing?* No Yes The following SOCIAL HISTORY information is kept strictly confidential.You may discuss this portion directly with the doctor if you’d prefer. YES, I would prefer to discuss my social history information directly with my doctor. Do you use cigarettes/tobacco? No Yes If yes, type/amount/how long? Do you drink alcohol? No Yes If yes, type/amount/how long? Do you use illegal drugs? No Yes If yes, type/amount/how long? REVIEW OF SYSTEMSDo you or an immediate family member currently have, or have had ever, any problems in the following areas? Please check YES or NO for you, and, if applicable, check FAMILY MEMBER and specify who (mother, father, sister, brother, etc).EARS, NOSE, THROAT* Yes No Family Member If family member, who? INTEGUMENTARY*Skin Yes No Family Member If family member, who? MENTAL*Anxiety, Depression Yes No Family Member If family member, who? HEADACHES / MIGRAINES* Yes No Family Member If family member, who? RESPIRATORY / ASTHMA* Yes No Family Member If family member, who? RESPIRATORY / COPD* Yes No Family Member If family member, who? HEART DISEASE* Yes No Family Member If family member, who? HIGH BLOOD PRESSURE* Yes No Family Member If family member, who? HIGH CHOLESTEROL* Yes No Family Member If family member, who? CANCER* Yes No Family Member If family member, who? GASTROINTESTINAL* Yes No Family Member If family member, who? GENITOURINARY* Yes No Family Member If family member, who? ENDOCRINE*Glands Yes No Family Member If family member, who? DIABETES MELLITUS* Yes No Family Member If family member, who? THYROID DISEASE* Yes No Family Member If family member, who? HORMONE REPLACEMENT* Yes No Family Member If family member, who? BIRTH CONTROL* Yes No Family Member If family member, who? BONES / JOINTS / MUSCLES*Arthritis Yes No Family Member If family member, who? LYMPHATIC/BLOOD* Yes No Family Member If family member, who? ALLERGIC / IMMUNOLOGIC* Yes No Family Member If family member, who? ALLERGIES*Seasonal/Other Yes No Family Member If family member, who? EYESBlurred Vision* Yes No Family Member If family member, who? Double Vision* Yes No Family Member If family member, who? Blindness / Loss of vision* Yes No Family Member If family member, who? Cataracts* Yes No Family Member If family member, who? Crossed eyes* Yes No Family Member If family member, who? Glaucoma* Yes No Family Member If family member, who? Macular degeneration* Yes No Family Member If family member, who? Retinal detachment / disease* Yes No Family Member If family member, who? Eye surgery*cataract/LASIK/RK Yes No Family Member If family member, who? Eye injuries* Yes No Family Member If family member, who? Other* PATIENT SIGNATURE - or -LEGAL GUARDIAN/PARENT*Date* MM slash DD slash YYYY