If YES, please list
Check any of the following you have had:
Check all that apply below:
REVIEW OF SYSTEMS (Please check below any of the conditions that apply to you)
FAMILY HISTORY
Please check below any family history for the following conditions and there relationship to youSOCIAL HISTORY
This information is kept strictly confidentialDo you use tobacco?
Do you drink alcohol?
Do you use illegal drugs?
Authorization for Treatment
I authorize Ronald D. Fisher, O.D., Jeffrey H. Yarrow, O.D., Chadwin L. Fleming, O.D., and/or any assistants as selected by them to examine, diagnose, and treat any eye related illness I may have. I understand that I am financially responsible for charges not covered by my insurance. I am also responsible for obtaining referrals if needed for medical related conditions.
Signature:
Date:
By typing your name above, you are stating the above information is accurate to the best of your knowledge and you are agreeing to the authorization for treatment.
Ocular and Medical History Questionnaire
List any medications you are taking below:
List any eye related injuries, surgeries, or hospitalizations:
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Eyes:
Ear, Nose, and Throat:
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Respiratory:
Vascular/Cardiovascular:
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Neurological:
Bones/Joints/Muscles:
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Gastrointestinal:
Lymphatic/Hematologic:
Urinary:
Endocrine:
Skin:
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Mother:
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Signature:
Date:
If you would like a copy for your review you may either print one from the link on our INSURANCE page of the website or you may request a hard copy when you arrive at our office on the day of your exam. (Navigating away from this page before submitting below will cause you to lose your data. Please open another window to review the privacy policy)
