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Brief Medical History Form
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* Indicates required question
Email
*
Your email
Patient Name
Name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Date of Your Exam
MM
/
DD
/
YYYY
Primary Care Physician, Location
Your answer
Review of Systems - list any health conditions
Your answer
Medications
Please list your current medications. Including dosing is not necessary.
Your answer
Medication Allergies
Your answer
Ocular History
Please describe your eye history briefly, including injuries and surgeries
Your answer
Family Ocular History
Please list significant eye conditions in immediate family (parents, grandparents, siblings)
Your answer
Smoking/Tobacco Status
Never Smoked
Former Smoker
Current Smoker
Clear selection
Are You a Contact Lens Wearer?
If yes, please bring boxes or lens packaging with you to your exam
Yes
No
Maybe - I would like to discuss options with the doctor
Clear selection
Other Notes
Your answer
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