Patient Medical History Form Name(Required) First Last Email(Required) Enter Email Confirm Email PhoneDate of Birth MM slash DD slash YYYY Eye SymptomsCheck if condition is in Left or Right Eye or BothLoss of vision Left Right Blurred vision Left Right Loss of side vision Left Right Flashes of light Left Right Floating spots/threads Left Right Double vision Left Right Wavy lines Left Right Dry eyes Left Right Watery eyes Left Right Eye Redness Left Right Eye pain/discomfort Left Right Light sensitivity Left Right Color Blindness Left Right Night Blindness Left Right Itchy eyes Left Right Glare/halos Left Right Blind spot in vision Left Right Eye Injury/trauma Left Right Other (specify) Left Right DescriptionGeneral SymptomsFever, fatigue, night sweats Yes No Headaches, hearing loss Yes No Cough, wheezing, difficulty breathing Yes No Chest pains, palpitations Yes No Vomiting, diarrhea, constipation Yes No Blood/pain urinating Yes No Unusual rashes Yes No Cold/heat intolerance Yes No Dizziness Yes No Emotional disturbances Yes No Joint pain/swelling, weakness Yes No Bruising/bleeding Yes No Numbness/Tingling Yes No Lifestyle & Medical HistoryDo you wear distance glasses? Yes No Do you wear contact lens? Yes No Do you have any food/drug allergies? Yes No Please List your food or drug allergiesDo you smoke? Current Everyday Current Some Days Former Never How many packs per day?How many years?Do you drink? Rarely Occasionally Socially Frequently No Formerly If applicable, are you pregnant or nursing? Yes No
