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?
Purpose of glasses:
Type of glasses:
Do you currently wear contact lenses?
Frequency of contact lens use:
Type of contact lenses:
Contact lens disposal schedule:
Are you interested in being fit for contact lenses today?
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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