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

2502 E. Oakland Park, Fort Lauderdale

Call Us 954-320-0048

Hours & Location
Specialty Eye Care
Eye Disease Diagnosis & Treatment
Eyewear
Our Clinic
Insurance

Hours & Location
Specialty Eye Care
Eye Disease Diagnosis & Treatment
Eyewear
Our Clinic
Insurance

Home » Contact Us » Patient History Form

Patient History Form

Please help us take better care of your overall health by completing the following form
Name*
First Last
Phone*
Email*
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
- Acquired Immune Deficiency
- Herpes Simplex
- Herpes Zoster
- HIV Positive
- Lyme Disease
- Measles
- Mumps
- Rubella
- Sarcoid
- Sjogren’s Syndrome
- Tuberculosis
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

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Broward Eye Care in Ft. Lauderdale

Monday:9:00 AM - 5:00 PM
Tuesday:9:00 AM - 6:00 PM
Wednesday:Closed
Thursday:9:00 AM - 6:00 PM
Friday:9:00 AM - 5:00 PM
Saturday:8:00 AM - 12:00 PM (alternate Saturdays)

Hours & Location
Specialty Eye Care
Eye Disease Diagnosis & Treatment
Eyewear
Our Clinic
Insurance

Hours & Location
Specialty Eye Care
Eye Disease Diagnosis & Treatment
Eyewear
Our Clinic
Insurance

Home
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Home
Contact Us
What’s New
DIRECTIONS
Disclaimer
Privacy Policy

Broward Eye Care - Located at 2502 E Oakland Park Blvd, Fort Lauderdale, FL, 33306. Phone: 954-564-2020. https://www.browardeye.com/

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