Brief Medical History Form
Medical History Form
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Patient Name
Patient Date of Birth
MM
/
DD
/
YYYY
Date of Your Scheduled Eye Exam
MM
/
DD
/
YYYY
Primary Care Physician and Location
Review of Systems - list any health conditions
Medications
Please list your current medications. Including dosing is not necessary.
Medication Allergies
Ocular History
Please describe your eye history briefly, including injuries and surgeries
Family Ocular History
Please list significant eye conditions in immediate family (parents, grandparents, siblings)
Smoking/Tobacco Status
Clear selection
Are You a Contact Lens Wearer?
If yes, please bring boxes or lens packaging with you to your exam
Clear selection
Other Notes
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