Patient Forms

Medical History Form

To reduce time in our waiting area you can complete the patient registration form below.
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Patient Information
Salutation:
Full Name:
Gender:
Date of Birth:
Current Address:
City:
Zip Code:
Phone 1:
Phone 2:
Email:
Employer:
Date of Last Eye Exam:
Date of Last Medical Exam:
Referral Source:
Name of Medical Doctor:
Doctors Phone:
Medical History
Do you have any allergies?
If yes, please explain:
Please list any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies):
Please list any major injuries, surgeries and/or hospitalizations you have had:
Please check any of the following conditions that you have had in the past:
Do you wear glasses?
If yes, how old is your current pair of glasses?
Do you wear contact lenses?
If yes, how old is your current pair of contact lenses?
What type of contact lenses do you wear?
Are they comfortable?
Family History
Please check any of the following conditions that you have had in the past and note any family history (parents, grandparents, siblings, children, both living and deceased) for the following conditions:
Relationship:
Relationship:
Relationship:
Relationship:
Relationship:
Relationship:
Relationship:
Relationship:
Relationship:
Relationship:
Relationship:
Relationship:
Relationship:
Relationship:
If there are any other conditions not listed please explain here:
Social History
This information is kept strictly confidential. However, you may discuss your condition directly with the doctor if you prefer.
I would prefer to discuss my social history information directly with my doctor:
Do you drive?
Do you have difficulty driving?
If Yes, please explain:
Do you use tobacco products?
If Yes, what type and how long?
Do you use illegal drugs?
If Yes, what type and how long?
Have you ever been exposed to or infected with Gonorrhea, Hepatitis, HIV, or Syphilis?
If Yes, please explain:
Review of Systems
Please check only those that apply if you currently, or have ever had any problems in the following areas:
Constitutional
Integumentary
Neurological
Ears, Nose, Throat, Mouth
Endocrine
Respiratory
Vascular/Cardiovascular
Gastrointestinal
Genitourinary
Eyes
Bones/Joints/Muscles
Lymphatic/Hematologic
Other
If you selected any of the above or have a condition not listed please explain here:

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Richmond:
(804) 353-3937
Midlothian:
(804) 888-8998
8048888998 8048888999 14431 Suite B Sommerville Court
Midlothian, VA 23113