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Eyecontact New Patient History Questionaire:

• New patients must fill out this for prior to making an appointment.
• Appointments must be made a least two week in advance.
• Conformations will be made via e-mail or phone.
( * denotes required field)

First Name:
Last Name:
Email:
 
Medical Information:
*What is your general physical health?
 
*Do you have problems with any of the following systems?
Gastrointestinal:
 Y N
Genitourinary:
 Y N
Ears/nose/throat:
 Y N
Musculoskeletal:
 Y N
Cardiovascular:
 Y N
Integumentary(skin):
 Y N
Respiratory:
 Y N
Mental:
 Y N
Allergic/Immunologic:
 Y N
Eyes:
 Y N
Nervous:
 Y N
Endocrine(glands):
 Y N
Blood/Lymph:
 Y N
 
 
*Please answer all that apply:
Diabetes:
Y N
Diabetes Type:
Date of diagnosis:
(MM/DD/YY)
Allergies:
Y N
Allergic To What?
What happends?
Medication Allergies?
   Y N
What happends?
Headaches?
Y N
Other health issues?
Current medications?
   
Family History:
 
Migraines? Y N
Who in your family has migrains? 
Diabetes? Y N
Who has diabetes? 
Glaucoma? Y N
Who has glaucoma? 
Muscular degeneration? Y N
Who has muscular degeneration? 
Retinal detachment ? Y N
Who has retinal detachment? 
Blindness? Y N
Who in your family is blind? 
Any other eye conditions? Y N
What kind?  
   
Personal Eye Information:  
Have you had any eye operations? Y N
What type?  
Date:   (MM/DD/YY)
Have you had any eye injuries? Y N
What kind of injuries? 
Date: (MM/DD/YY)
 
 
 
Property of Eyecontact, Optometry. All rights reserved.
Eyecontact, Optometry. 350 N. Santa Cruz Ave., Los Gatos, CA 95030
Phone (408) 395-3934 • Fax (408) 395-4784 • Email: info@eyecontact.biz
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