intake3

MytestForm1

To create Medical History Of Patient
    • MEDICAL HISTORY

    • To comply with medical record requirements, please complete the following information.

    • Patient Name

    • Birthdate

    • DD slash MM slash YYYY
    • Gender

    • Primary Care Physician

    • Pharmacy

    • Last Medical Exam

    • Last Eye Exam

    • What is the reason for today's eye exam ? Please mark all that apply.

    • Have you had an eye injury?

    • Have you had an eye surgery?

    • How old are your current glasses ?

    • How old is the pair of contacts that you are currently wearing ?

    • What brand of contacts do you currently wear ?

    • Are you happy with your current contact lenses ?

    • Do you sleep in your contacts ?

    • How often do you replace your contact lenses ?

    • Do you have, or have you ever been treated for ? Please mark all that apply.

    • Do you take any medications ?

    • Do you have allergies ?

    • Do you smoke?

    • Do you drink alcohol ?

    • Do you have a history of recreational drug use?

    • Does anyone of your family members have any of the following medical problems ? Please mark all that apply.