Medical History Record
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Patient's Name *
Date of Birth *
MM
/
DD
/
YYYY
M or F *
Street Address *
City, State, Zip Code *
Preferred Phone Number *
Emergency Contact Name *
Emergency Contact Phone Number *
Occupation
Date of Last Eye Exam
MM
/
DD
/
YYYY
Personal Medical Information: Do you have any problems with any of these systems? Check all that apply. *
Required
Are you in good health? *
Any allergic reactions to medications or other substances? If yes, please list. *
Name of General Physician *
Do you smoke? If yes, how much? *
Do you drink alcohol? I yes, how much?
Do you take medications? If yes, please list.
Do you have family history of any of the following? If yes, please check all that apply. *
Required
Do you have any fo the following? Please check all that apply. *
Required
Any eye problems at this time? Please explain. *
Are you interested in laser vision correction?
Clear selection
Please sign (type you full name) below that you have reviewed all information above and it is correct to the best of your knowledge. *
Today's Date *
MM
/
DD
/
YYYY
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