New Patient Form Health History QuestionnairePatient name First Last Date of Birth MM slash DD slash YYYY Who is your current primary care provider?Name PhoneDo you currently wearGlasses Distance only Reading only Bifocal Trifocal Progressive Contacts Soft Lenses Rigid Gas Perm Lenses Scleral Lenses Keratoconus Lenses What complaints do you have about your current vision correction, or your eyes today?Are you Pregnant? Yes No Are you Current Smoker? Yes No How many packs per day? For how many years? Are you Former Smoker? Yes No How long ago did you quit? Are you Smokeless tobacco user? Yes No Please list all medical conditions you have been diagnosed withIf you are diabetic, who is your managing Dr.? PhonePlease list all medications you are currently taking, including any vitamins, supplements, and eye dropsPlease list any allergies you have to medications, food, or the environment.Please list any unusual eye history for yourselfPlease list any unusual eye history for your immediate family. (Including cataracts)
