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Medical History Form

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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.

Patient Information

Name *
*
*
*
Please provide a telephone number, with area code, so we can contact you.
Please provide your email address.
*
Gender

Medical History

Do you have any allergies to medications?
Include Name of Medication, Dosage, Frequency Taken
Check any of the following that you have had:
Are you pregnant or nursing?
Do you wear glasses?
Do you wear contact lenses?
Type of Contact Lenses:
Are they comfortable?

Family History

Note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.
Disease/Condition

Social History

This information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer. Please check the box below if you prefer to discuss with the doctor instead.
I prefer to discuss my Social History information directly with my doctor.
Do you drive?
If Yes, do you have visual difficulty when driving?
Do you use tobacco products?
Do you drink alcohol?
Do you use illegal drugs?
Have you ever been exposed to or infected with:

REVIEW OF SYSTEMS

Do you currently or have you ever had any problems in the following areas?

Constitutional

Fever, Weight Loss/Gain
Integumentary (Skin)

Neurological

Headaches
Migraines
Seizures

Eyes

Loss of Vision
Blurred Vision
Distorted Vision/Halos
Loss of Side Vision
Double Vision
Dryness
Mucous Discharge
Redness
Sandy or Gritty Feeling
Itching
Burning
Foreign Body Sensation
Excess Tearing/Watering
Glare/Light Sensitivity
Eye Pain or Soreness
Chronic Infection, Eye or Lid
Sties or Chalazion
Flashes/Floaters in Vision
Tired Eyes

Endocrine

Thyroid/Other Glands
Elevated Cholesterol
Cancer

Ears, Nose, Mouth, Throat

Sinus Congestion
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Throat/Mouth
Allergies/Hay Fever

Respiratory

Asthma
Chronic Bronchitis
Emphysema

Vascular/Cardiovascular

Diabetes
Heart Pain
High Blood Pressure
Vascular Disease

Gastrointestinal

Diarrhea
Constipation

Genitourinary

Genitals/Kidney/Bladder

Bones/Joints/Muscles

Rheumatoid Arthritis
Muscle Pain
Joint Pain

Lymphatic/Hematologic

Anemia
Bleeding Problems

Allergic/Immunologic

Allergic/Immunologic

Psychiatric

Psychiatric
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Strong Vision Center

monday:
9:00 am - 6:00 pm
tuesday:
8:00 am - 7:00 pm
wednesday:
9:00 am - 6:00 pm
thursday:
9:00 am - 6:00 pm
friday:
9:00 am - 6:00 pm
saturday:
Closed
sunday:
Closed

Strong Vision Center Fairfield

monday:
9:00 am - 6:00 pm
tuesday:
8:00 am - 7:00 pm
wednesday:
9:00 am - 6:00 pm
thursday:
9:00 am - 6:00 pm
friday:
9:00 am - 6:00 pm
saturday:
Closed
sunday:
Closed