Medical History Form

Full Name*

Date of Birth*

Phone*

Email*

Address*

I consent to the use of electronic communication (text or email) for appointment reminders, recalls and other notices. By not checking this box, I agree to not receive recall notices when I am due for my next appointment(s).

What is the main reason for your today (ex: routine vision exam, dry eyes, itching, blurry vision):

Do you have any drug, seasonal, or environmental allergies?*

Have you ever had an eye infection, injury, or surgery?*

Do you experience flashes of light?*

What is your smoking status?*

Have you diagnosed with any of the following: (Check all that apply)

Have you or any blood relatives been diagnosed with the following?

Do you take any medications (including multivitamins, aspirin, vitamins, birth control, etc)?