Home 5 Patient Forms 5 Patient Social and Family History Patient Social and Family HistoryPlease print or type all information. For assistance, please call 855-734-2020. Phone Patient Name * Date of Birth * Pharmacy Name * Pharmacy Phone Number * Gender * Male Female Preferred Language * English Spanish French German Other If other, please specify Race * White African American Asian Black African American Mexican American Indian Other If other, please specify Ethnicity * Not Hispanic or Latino Mexican Latin American Smoking History * Never Smoked Quit Smoking Currently SmokeFamily HistoryCheck all that apply and explain if related to self or relative Macular Degeneration * Yes No If Yes Retinal Detachment * Yes No If Yes Glaucoma * Yes No If Yes Diabetes * Yes No If Yes Ocular History Have you had Lasik? * Yes No Do you wear Contact Lenses? * Yes No Have you worn contacts in the past? * Yes No Do you have macular degeneration? * Yes No Have you had cataract surgery? * Yes No Please list any other eye surgeries or eye disease that you have or have had. Review of SystemsPlease check each item yes or no as they relate to your healthEyes Pain * Yes No Double Vision * Yes No Floaters * Yes No Dry Eyes * Yes No Decreased Vision * Yes No Excessive Tears * Yes No Sandy Feeling * Yes NoMusculoskeletal Joint Pain * Yes No Stiffness * Yes No Arthritis * Yes NoEar, Nose, Throat Hard of Hearing * Yes No Ringing in Ears * Yes No Vertigo * Yes NoGastrointestinal Problems Stomach * Yes No Liver * Yes NoBlood/Lymph Easy Bruising * Yes No Blood Thinners * Yes No Anemia * Yes NoKidney/Urinary Problems Prostate * Yes No Bladder * Yes No Kidney * Yes NoCardiovascular Chest Pain * Yes No HTN * Yes No Heart Attack * Yes No If yes, when? Pacemaker * Yes No Dizziness * Yes NoNeurological Seizures * Yes No Stroke * Yes No Alzheimer's * Yes NoPsychiatric Anxiety * Yes No Depression * Yes No Past Medical Surgical History and any illness not listed previously. Please include dates. Allergies (please list all) Are any of your medical conditions bothering you today? If so please explain? Digital Signature * Date * Submit
