New Patient Medical History Form

Name: Estrella Mountain Eye Care, PLLC
Address: 13065 W McDowell Road Ste B105, Avondale, AZ, 85392, US
Telephone: 623-663-0423
Price range: $000 - $300

Please note: This form must be completed in full before you can submit it.
If there is nothing to list, write “N/A” (not applicable).

Gender
- Male
- Female
Patient Name*
First Last
Birthdate*
Month
Day
Year
When was your last eye exam?
Who did your eye exam?
Do you wear glasses?*
- No
- Yes
If yes, how old is your present pair of lenses?
Do you wear Contact Lenses?*
- No
- Yes
If yes, how old is your present pair of lenses?
Are you interested in Contact Lenses?*
- No
- Yes
Are you interested in Colored Contact Lenses?*
- No
- Yes
Name of Medical Doctor
Dr Phone #
Dr Fax #
List any medications you currently take, as well as eye drops:
Do you have any allergies to any medications?*
- No
- Yes
Explain:
List any eye injuries or eye surgeries:
iInclude which eye and date of occurrence(s)
Injury Which eye? Date of occurrence
Are you pregnant and/or nursing?*
- No
- Yes
The following SOCIAL HISTORY information is kept strictly confidential.
You may discuss this portion directly with the doctor if you’d prefer.
- YES, I would prefer to discuss my social history information directly with my doctor.
Do you use cigarettes/tobacco?
- No
- Yes
If yes, type/amount/how long?
Do you drink alcohol?
- No
- Yes
If yes, type/amount/how long?
Do you use illegal drugs?
- No
- Yes
If yes, type/amount/how long?
REVIEW OF SYSTEMS
Do you or an immediate family member currently have, or have had ever, any problems in the following areas? Please check YES or NO for you, and, if applicable, check FAMILY MEMBER and specify who (mother, father, sister, brother, etc).
EARS, NOSE, THROAT*
- Yes
- No
- Family Member
If family member, who?
INTEGUMENTARY*
Skin
- Yes
- No
- Family Member
If family member, who?
MENTAL*
Anxiety, Depression
- Yes
- No
- Family Member
If family member, who?
HEADACHES / MIGRAINES*
- Yes
- No
- Family Member
If family member, who?
RESPIRATORY / ASTHMA*
- Yes
- No
- Family Member
If family member, who?
RESPIRATORY / COPD*
- Yes
- No
- Family Member
If family member, who?
HEART DISEASE*
- Yes
- No
- Family Member
If family member, who?
HIGH BLOOD PRESSURE*
- Yes
- No
- Family Member
If family member, who?
HIGH CHOLESTEROL*
- Yes
- No
- Family Member
If family member, who?
CANCER*
- Yes
- No
- Family Member
If family member, who?
GASTROINTESTINAL*
- Yes
- No
- Family Member
If family member, who?
GENITOURINARY*
- Yes
- No
- Family Member
If family member, who?
ENDOCRINE*
Glands
- Yes
- No
- Family Member
If family member, who?
DIABETES MELLITUS*
- Yes
- No
- Family Member
If family member, who?
THYROID DISEASE*
- Yes
- No
- Family Member
If family member, who?
HORMONE REPLACEMENT*
- Yes
- No
- Family Member
If family member, who?
BIRTH CONTROL*
- Yes
- No
- Family Member
If family member, who?
BONES / JOINTS / MUSCLES*
Arthritis
- Yes
- No
- Family Member
If family member, who?
LYMPHATIC/BLOOD*
- Yes
- No
- Family Member
If family member, who?
ALLERGIC / IMMUNOLOGIC*
- Yes
- No
- Family Member
If family member, who?
ALLERGIES*
Seasonal/Other
- Yes
- No
- Family Member
If family member, who?
EYES
Blurred Vision*
- Yes
- No
- Family Member
If family member, who?
Double Vision*
- Yes
- No
- Family Member
If family member, who?
Blindness / Loss of vision*
- Yes
- No
- Family Member
If family member, who?
Cataracts*
- Yes
- No
- Family Member
If family member, who?
Crossed eyes*
- Yes
- No
- Family Member
If family member, who?
Glaucoma*
- Yes
- No
- Family Member
If family member, who?
Macular degeneration*
- Yes
- No
- Family Member
If family member, who?
Retinal detachment / disease*
- Yes
- No
- Family Member
If family member, who?
Eye surgery*
cataract/LASIK/RK
- Yes
- No
- Family Member
If family member, who?
Eye injuries*
- Yes
- No
- Family Member
If family member, who?
Other*
PATIENT SIGNATURE - or -LEGAL GUARDIAN/PARENT*
Date*
MM slash DD slash YYYY

Injury	Which eye?	Date of occurrence

The following SOCIAL HISTORY information is kept strictly confidential.

REVIEW OF SYSTEMS

EYES

Estrella Mountain Eye Care, PLLC