New Patient Intake

New Patient Intake

New Patient Intake

New Patient Intake

Please fill up the forms as completely as you can.


Medical History



List any of the following that you have had

Have you considered:

Do you have a problem with any of the following:


Family History

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

Blindness

Cataract

Crossed Eyes

Glaucoma

Macular Degeneration

Retinal Detachment/Disease

Arthritis

Cancer

Diabetes

Heart Disease

High Blood Pressure

Kidney Disease

Lupus

Thyroid Disease

Other

Other

Other


​​​​​​​Social History

Do you drive?

If yes, do you have difficulty when driving?

Do you use tobacco products?

Do you drink alcohol?

If yes,

Vocation


​​​​​​​Review of Systems

Constitutional

Ear, Nose, Mouth, Throat

Vascular/Cardiovascular

Integumentary (skin)

Neurological

Eyes

Endocrine

Gastrointestinal

Genitourinary

Bones/Joints/Muscles

Allergic/Immunologic

Psychiatric


Please do not submit any Protected Health Information (PHI).
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