Patient Information and Medical History Form

Thank you for using our secure online forms. Please fill out as much information as you can. Note that the available options for marital status, race and ethnicity are the options required by the US Government. They also include Latino/Hispanic heritage under ethnicity and consider it independent of race.

When you are finished be sure to hit the submit button at the bottom of the form. If you have any questions, please call us at (610) 562-4548. We can always change the data in the office if you are unsure about what to enter in any of the fields.

Patient Information

*required (first and last name and either a home OR cell phone)

City St  Zip
Hm Phone*
Cell Phone*
Wk Phone
Other Phone
Preferred Contact By
DOB (mm/dd/yyyy)  
Sex Female Male
Marital Status
Employment Status Employed FT Student PT Student
Preferred Language

Who may we thank for referring you to our office?  

Billing Information

Is The Billing Address the Same?

City St  Zip
Hm Phone  
Wk Phone

General Medical History

Primary physician's name and phone  
When was your last physical exam?

Check the box for any conditions that apply to you, your parents or siblings:

You Mom Dad Sib Describe (type, when were you diagnosed, etc)
If YOU are diabetic, when were you diagnosed?    Last A1C level? 
Height  ft   in        Weight  lbs        Are you Pregnant or Nursing?  
List ALL major injuries or surgeries you have had and approx dates:
List any other medical conditions you have had, including non-drug allergies:
List all Rx and over-the-counter medications you currently take:
List any vitamins or supplements you currently take:
List any drug allergies you have:
Smoking Status
Alcohol Use
Do you live alone?  

Review of Systems

Please list any problems you are currently having anywhere, from head to toe:

General (e.g., fever, fatigue, loss of appetite, unexplained weight loss/gain)
Ear, Nose, Throat (e.g., sinus problems, post-nasal drip, runny nose, dry mouth/throat, sleep apnea, hearing problems)
Cardiovascular (e.g., chest pain, racing heartbeat, swollen feet/ankles, TIAs, cholesterol)
Respiratory (e.g., chronic cough/bronchitis, asthma, COPD, emphysema, shortness of breath, wheezing)
Genital, Kidney, Bladder (e.g., bladder/urinary problems, pain, menstrual changes, impotence)
Gastrointestinal (e.g., crohn's disease, ulcerative colitis, gastric reflux (GERD))
Endocrine (e.g., heat or cold intolerance, thinning hair, excess thirst, excess urination)
Muscles, Bones, Joints (e.g., joint pain, muscle pain, stiffness, weakness, limited movements, rheumatoid arthritis, osteoarthritis)
Skin (e.g., eczema, psoriasis, rosacea, rash)
Neurological (e.g., headaches, migraines, seizures, numbness, dementia, concussions, vertigo, poor balance, strokes, MS)
Psychiatric (e.g., depression, anxiety, sleep problems, paranoia, obsessive/compulsive, bipolar, attention issues(ADHD))
Blood/Lymph (e.g., anemia, bleeding problems, delayed clotting)
Allergy/Immune (e.g., itching, sneezing, runny nose/eyes, guillian-barre syndrome, lupus)

Ocular History

Who was your previous eye doctor?  
When was your last eye exam?

Check the box for any conditions that apply:

You Mom Dad Sib Describe (type, when diagnosed, which eye(s), treatment,etc)
Macular Degeneration
Retinal problems
Lazy Eye/Eye Turn
List any major eye injuries, infections or surgeries and approx dates:
List any other significant eye problems you have had:
List all Rx and over-the-counter eye medications you currently use:
List any vision complaints you are currently having such as:
  • blurred vision, headaches, eyestrain, double vision, or losing your place when reading
  • itching, burning, redness, pain, sensitivity to light, watering, crusting or mucus discharge
  • seeing rainbows around white lights at night, flashes of light or dark spots/squiggles/webs
How many hours/day do you typically spend using a computer or other digital devices?
If you are having complaints with computer work, how far is the monitor from your eyes? 
How many hours/day do you typically spend reading books, magazines, etc?
What are your hobbies/sports activities?
Do you wear glasses?
How old are your glasses?
Do you have sunglasses?
Do you have back-up glassess?
Are you interested in contacts?
Contact Lens Wearers Only
What disinfecting solution do you use?
How long do you usually wear your lenses?
How often do you replace your lenses?
How old is your current pair of contacts?

You're Done! Please hit the Submit button below.