Patient History Form

Please complete the information below and submit the form online or, if you prefer, print out the form after full or partial completion and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Please help us take better care of your overall health by completing the following form

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Number*

Please provide a telephone number, with area code, so we can contact you.

Cell Phone

Work Phone

Email Address

Please provide your email address.

Employer

Occupation

Date of Birth*

Social Security Number (last 4 digits only!)

Please enter a value between 0000 and 9999.

Race/Ethnicity

Preferred Language

Gender

Female
Male

Who may we thank for referring you to our office?

Date of Last Medical Exam

Name of Medical Doctor

Doctor's Phone Number

Date of Last Eye Exam

Current Height

Current Weight

Spouse or Guardian (If Applicable)

PLEASE CHECK ALL THAT APPLY

OCULAR HISTORY

Cataract
Glaucoma
Retinal Detachment
Macular degeneration

OCULAR SURGERY

Cataract
Glaucoma
Retinal Laser

MEDICAL HISTORY

Medications

Allergy Meds

Allergy Other

REVIEW OF SYSTEMS

CARDIOVASCULAR

Elevated Cholesterol
Heart Disease
Hypertension

ENDOCRINE

Crohn’s Disease
Diabetes Mellitus
Pituitary Disorder
Renal (kidney) Disorder
Thyroid Disorder

GASTROINTESTINAL

Acid Reflux
Cancer, Colon, Liver, Lung
Gall Bladder
Hepatitis
Gastritis
Pancreatitis

GENITOURINARY

Ovarian Disorder
Prostate Disorder

EAR, NOSE, MOUTH, THROAT

Dry Mouth
Ear Infection
Headaches
Migraine Headaches
Sinusitis

IMMUNOLOGIC

NEUROLOGICAL

Bell’s Palsy
Headache
Headache Migraine
Nystagmus
Parkinson’s Disease
Seizure Disorder

RESPIRATORY

Asthma
Bronchitis
Lung Disease
Smoker
Tuberculosis

HEMATOLOGIC/LYMPHATIC

Anemia
Blood Coagulation Disorder
Blood Disorder
Sickle Cell Disease

INTEGUMENTARY (SKIN)

Acne
Acne Rosacea
Dermatitis
Lupus

MUSCULOSKELETAL

Arthritis
Muscular Dystrophy
Myasthenia Gravis
Skeletal Disorder

PSYCHIATRIC

Anxiety Disorder
Dementia
Depression
Mood Disorder

PRIMARY CARE PHYSICIAN

PHONE

FAX

One block East of Federal Hwy, directly across Target and the Coral Ridge Mall

Patient History Form

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