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Patient Social and Family History Form

Patient Social and Family History

Please print or type all information. For assistance, please call 855-734-2020.

"*" indicates required fields

MM slash DD slash YYYY
Gender*
Preferred Language*
Race*
Ethnicity
Smoking History

Family History

Check all that apply and explain if related to self or relative

Macular Degeneration*
Retinal Detachment*
Glaucoma*
Diabetes*

Ocular History

Have you had Lasik?*
Do you wear Contact Lenses?*
Have you worn contacts in the past?*
Do you have macular degeneration?*
Have you had cataract surgery?*

Review of Systems

Please check each item yes or no as they relate to your health

Eyes

Pain*
Double Vision*
Floaters*
Dry Eyes*
Decreased Vision*
Excessive Tears*
Sandy Feeling*

Musculoskeletal

Joint Pain*
Stiffness*
Arthritis*

Ear, Nose, Throat

Hard of Hearing*
Ringing in Ears*
Vertigo*

Gastrointestinal Problems

Stomach*
Liver*

Blood/Lymph

Easy Bruising*
Blood Thinners*
Anemia*

Kidney/Urinary Problems

Prostate*
Bladder*
Kidney*

Cardiovascular

Chest Pain*
HTN*
Heart Attack*
MM slash DD slash YYYY
Pacemaker*
Dizziness*

Neurological

Seizures*
Stroke*
Alzheimer's*

Psychiatric

Anxiety*
Depression*
MM slash DD slash YYYY

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