Frisco Family Eyecare

Please fill out the Medical History Form Below

GENERAL INFORMATION
   * First* LastMISuffixNickname
* Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone:
* Cell Phone: Preferred Contact Method:
SSN Email
* Birthday
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian
PATIENT  DEMOGRAPHIC INFORMATION
Who Referred you to the practice? 
* * *
* What is your occupation? Who is your Employer? Hobbies:

Are you the patient's Parent or Guardian? Does the patient live alone?   Do you use alcohol? Please Explain: 
PATIENT MEDICAL HISTORY When was your last physical exam? 
* Height (FT):  (IN):   *Weight (LBS): 
Are you Pregnant or Nursing? 
* REASON FOR VISIT: 

Are you Diabetic? 
What year were you diagnosed? 
  What was your most recent A1c reading?   Date: 
Do you have High Blood Pressure? 
Do you have High Cholesterol? 
Do you have Thyroid Issues? 
Do you have Cardiovascular Disease? 
Do you have Cancer? 
Do you have Rheumatoid Arthritis? 
Do you have Sleep Apnea? 

Other Medical History (please explain):

Family Medical History:

MEDICATION INFORMATION
Please list any medications you are currently taking: No Current Medications

Please list any eye drops you are currently using:                     No Topical Medications

Please list any Drug Allergies:                                                         No Known Drug Allergies
VISUAL HISTORY
Do you have Glaucoma? 
Do you have Cataracts? 
Do you have issues with Amblyopia/Lazy Eye? 
Other Visual History Issues (please explain):

Have you had any Eye Surgeries? (Type, Eye and Year):

Family Eye History (Please Include Who):


Thank You So Much! We look forward to seeing your at your upcoming visit!



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