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Patient Medical History

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Patient Medical History

Today's Date*
Date Format: MM slash DD slash YYYY
Name*
First Last
Date of Birth*
Pharmacy Address*
Street Address Address Line 2 City State ZIP Code
Referring Physician
Your Eye History
Cataract Surgery*
- Yes
- No
If yes, which eye and approximate date*
Laser Eye Surgery*
- Yes
- No
If yes, which eye and approximate date*
Other Eye Surgery*
- Yes
- No
If yes, which eye and approximate date*
Eye Disease/Injury*
- Yes
- No
If yes, which eye and approximate date*
Other Eye Problems*
- Yes
- No
If yes, which eye and approximate date*
Do you wear:
- Glasses
- Contacts
Cardiovascular*
- Heart Disease
- High Blood Pressure
- Other
- None
Genitourinary*
- Kidney Disease
- Renal Failure
- Chronic UTI
- Other
- None
Immunologic*
- Shingles
- Hay fever
- Lupus
- Sarcoidosis
- HIV
- Other
- None
Muscular Skeletal*
- Osteoarthritis
- Rheumatoid Arthritis
- Carpal Tunnel
- Osteoporosis
- Other
- None
Dermatologic*
- Skin Condition
- Acne/ Rosacea
- Stevens-Johnson Syndrome
- Other
- None
HEENT*
Head, Ears, Eyes, Nose, and Throat
- Skin Problems
- Hearing Loss
- Mouth Sores
- Other
- None
Infectious Disease*
- Hepatitis A B C
- Herpes
- TB
- HIV
- MRSA
- Other
- None
Neoplastic*
- Cancer
- Breast Cancer
- Ovarian Cancer
- Colon Cancer
- Lung Cancer
- Brain Tumor
- Prostate Cancer
- Skin Cancer
- Other
- None
Pulmonary*
- Lung Disease
- Asthma
- Emphysema
- Sleep Apnea
- Bronchitis
- COPD
- Other
- None
Gastrointestinal*
- Stomach Problems
- Liver Disease
- GERD
- Gastric
- Ulcer
- Diverticulitis
- Other
- None
Hematologic*
- Bleeding Disorder
- Anemia
- Coumadin Therapy
- Other
- None
Metabolic/Endocrine*
- Non-Insulin dependent, Diabetes
- Insulin dependent Diabetes
- Thyroid Disease
- Graves Disease
- Pituitary Tumor
- Other
- None
Neuro/Psychiatric*
- Stroke: R L
- Migraine Headaches
- TIAs
- Depression
- Anxiety syndrome
- Post-Traumatic Stress Disorder
- Bells Palsy
- Parkinsons
- None
Women's Health*
- Pregnancy
- Child Birth
- Not Applicable
If others, please list:*
General Physician*
Physician's Phone Number*
Date*
Physician's Address*
Street Address Address Line 2 City State ZIP Code
List any other major ILLNESSES, HOSPITALIZATIONS, and SURGERIES. (with the year if possible)*
Date*
*
*
*
*
*
*
*
*
Medications
Eye Medication*
Date*
Other Medications*
Date*
Are you ALLERGIC to any Medications*
- Yes
- No
If YES, please list:*
Family Medical History
Cataracts*
- Yes
- No
If yes, what is their relationship to you?*
Glaucoma*
- Yes
- No
If yes, what is their relationship to you?*
Cornea Problems*
- Yes
- No
If yes, what is their relationship to you?*
Retina Detachment*
- Yes
- No
If yes, what is their relationship to you?*
Blindness*
- Yes
- No
If yes, what is their relationship to you?*
Other*
- Yes
- No
If yes, what is their relationship to you?*
Diabetes*
- Yes
- No
If yes, what is their relationship to you?*
Heart Disease*
- Yes
- No
If yes, what is their relationship to you?*
Cancer*
- Yes
- No
If yes, what is their relationship to you?*
Do you smoke?*
- Yes
- No
Do you drink?*
- Yes
- No
Use/Abuse Drugs?*
- Yes
- No
Email
This field is for validation purposes and should be left unchanged.

Nashville

2400 Patterson St.
Suite 201
Nashville, TN 37203

Phone: 615.320.7200
Fax: 615.320.7203
Email: info@corneaconsultants.net

Office Hours
M - T: 8:00am - 5:00pm
F: 8:00am - 1:00pm

Franklin

3326 Aspen Grove Dr
Building B, Suite 200
Franklin, TN 37067

Phone: 615.320.7200
Fax: 615.716.2183
Email: info@corneaconsultants.net

Office Hours
M - Th: 7:30am - 4:30pm
F: 7:30am - 1:00pm

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