Patient Information
Personal Identification Code or Name :*
Home phone: *
Work phone:
E-mail confirmation: *
Country of Residence: *
Preferred contact:
Birthdate (mm/dd/yyyy): *
Sex: *
Height : *
Weight: *
Medical History
List any medications you take including herbal medications :
List all major illnesses or injuries (diabetes, high blood pressure, emphysema, heart attacks, etc):
Do you have any allergies to medications? *
If yes, please list the medications:
List any surgeries you have had:
List all eye illnesses or injuries (crossed/lazy eye, cataract, glaucoma, macular degeneration, abrasions, etc.):
Do you currently have any problems in the following areas?
Yes
No
If yes, please explain:
General / Constitutional (fever, weight loss, other)
Ears, Nose, and Throat (cold, sinus, chronic cough)
Cardiovascular (heart, vessels, etc.)
Respiratory (asthma, emphysema, etc.)
Gastrointestinal (ulcers, intestinal disease, etc.)
Genital, Kidney, Bladder
Skin (rosacea, skin cancer, psoriasis, etc.)
Neurological (MS, stroke, seizures, etc.)
Psychiatric (anxiety, depression, etc.)
Endocrine (diabetes, thyroid, etc.)
Blood / Lymph (bleeding disorder, high cholesterol, anemia, etc.)
Allergic / Immunologic (lupus, hay fever, rheumatoid arthritis, etc.)
