Medical History Form Step 1 of 2 50% Appointment Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient's Name* First Last Birth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex Male Female Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work PhoneEmployer Occupation Emergency Contact Emergency Contact Phone NumberDate of Last Eye ExamMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name of Previous Eye Doctor Personal Medical Information: Do you have problems with any of these systems? If yes, please check box. Gastrointestinal Ear/Nose/Throat Cardiovascular Respiratory Headaches Nervous System Genitourinary Musculoskeletal Skin Mental Endocrine (Glands) Blood/Lymph Allergic/Immunologic Surgeries What type of surgery and when?Are you in good health?* Yes No Any allergic reactions to medication or other substances?* Yes No Please list.Name of General Physician Please check Yes or NoDo you smoke?* Yes No How much? Do you drink alcohol?* Yes No How much? Do you take medications?* Yes No Please list names and how oftenDo you use other stubstances?* Yes No Do you have family history of any of the following? If yes, please check box. Diabetes Glaucoma High Blood Pressure Macular Degeneration Retinal Detachment Cataracts Please ExplainDo you have any of the following? If Yes, please check box. Dry Eyes Eye Surgeries Wear Glasses Blurred Vision Eye Injuries Wear Contacts Please ExplainAre you interested in laser vision correction?* Yes No Please sign below that you have reviewed all information above and it is correct to the best of your knowledge.Signature*Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PhoneThis field is for validation purposes and should be left unchanged. Office Hours & Info Monday7:00am - 5:00pmTuesday8:00am - 7:00pmWednesday8:00am - 5:00pmThursday8:00am - 5:00pmFriday8:00am - 1:00pmSaturdayClosedSundayClosed 1408 43rd StreetMaquoketa, IA52060 563-652-2795 563-652-5210 [email protected]
