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WELCOME!

FIRST VISIT WITH US?

We look forward to meeting you!

Fill out the form below, or if you prefer, you can download a PDF form to print and fill out a hard copy.

NEW PATIENT QUESTIONNAIRE

Gender
Circle appropriate selection

Please check appropriate answers:

Constitutional

Fever, Weight Loss/Gain
Cancer

Ear, Nose, Mouth, Throat

Dry Throat/Mouth
Hearing Loss
Sinusitis

Neurological

Seizures/Epilepsy
Tension Headaches
Tumor
Multiple Sclerosis
Migraines

Psychiatric

Anxiety/Depression
Other

Vascular/Cardiovascular

Heart Disease
High Blood Pressure
Stroke

Respiratory

Asthma
Sleep Apnea
Emphysema
Chronic Bronchitis

Gastrointestinal

Acid Reflux
Crohn’s Disease

Genitourinary

Pregnant
Nursing
Prostate disease

Bones/Joints/Muscles

Rheumatoid Arthritis
Osteoporosis
Muscle/Joint Pain

Integumentary

Shingles/Herpes Zoster
Cold Sores/Herpes Simplex
Rosacea

Endocrine

Type 1 Diabetes
Type 2 Diabetes
Thyroid Dysfunction

Lymphatic/Hematologic

High Cholesterol
Anemia

Allergic/Immunologic

Seasonal Allergies
Sjogren’s Syndrome
Lupus
Do you have any allergies to medication?
Have you ever been exposed to or infected with:

OCULAR HISTORY: Please check reason(s) for visit 

Loss of Vision
Eye Pain or Soreness
Eye Injury
Blurred Vision
Chronic Infection of Eye or Lid
Dryness
Distorted Vision/Halos
Sties or Chalazion
Redness
Double Vision
Flashes/Floaters in Vision
Sandy or Gritty Feeling
Glare/Light Sensitivity
Retinal Disease
Itching
Burning
Foreign Body Sensation
Excess Tearing/Watering
Glaucoma
Cataract
Lazy Eye
Crossed Eyes

FAMILY HISTORY

Please note any family history (parents, grandparents, siblings, children...living or deceased) for the following conditions: 

Cancer
Diabetes
High Blood Pressure
Thyroid Disease
Heart Attack
Stroke
Cataract
Macular Degeneration
Glaucoma
Crossed Eyes
Amblyopia
Retinal Detachment

SOCIAL HISTORY

(This information is kept strictly confidential.)

Do you drive?
If yes, do you have visual difficulty when driving?
Do you drink alcohol?
Do you use tobacco products?
Do you use illegal drugs?

GLASSES/CONTACT LENS HISTORY

Do you wear glasses?
Do you wear contact lenses?
Are they for:
Are they comfortable?
Type of contact lenses:

Thank you! We will contact you shortly!