Medical History

Please complete the following medical history form. If you have not completed the patient information section, please do that prior to filling out this form.

Please wear a mask of you are experiencing any mild symptoms such as runny nose or cough.
Do you currently wear glasses?
Do you currently wear contact lenses?
Do you experience any of the following ocular symptoms?
Have you undergone any eye surgery (LASIK/PRK/Cataract etc)?
Please indicate all health conditions that apply to YOU:
Please indicate all health conditions that apply to your IMMEDIATE FAMILY:
Please list all medications you are taking (if none, please write 'none'):
Please list any allergies to medications you may have (if none, please write 'none'):
Please indicate the number of hours of computer usage/screen time per day:
Our doctors highly recommend the ​OPTOMAP RETINAL SCREENING for all of our patients as part of their yearly exam for the following reasons: it is a ​non-invasive technique​ to examine the health of your eye, without the side effects of drops or blurry vision. It provides a​ high resolution picture​ which is comparable to future visits. It allows for the ​detection of eye diseases and retinal lesions which can be present without any symptoms. The ​Optomap Retinal Screening contributes to our standard of care and improves patient education and satisfaction. There is a nominal charge of $34​ for this procedure, ​that is not​ covered by insurance
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