Medical History Form 

Today’s Date:                /            /                                                              Birth date:            /             /           

Name:                                                                                                                                                                       

Home Address:                                                                                                                                                       

                                                No. & Street                                           City                         State                       Zip

Work Address:                                                                                                                                                        

                                                No. & Street                                           City                         State                       Zip

Home Phone:(          )                                                           Work Phone: (           )                                              

Employer:                                                                 Occupation:                                                                        

Are you now or have you been under the care of a physician within the last two years?                      

If yes, please provide Physician’s Name, address and phone number.                                                                                                                                                                                                                                              

Person to contact in an emergency:           Medical History Form

Today’s Date:                /            /                                                              Birth date:            /             /           

Name:                                                                                                                                                                       

Home Address:                                                                                                                                                       

                                                No. & Street                                           City                         State                       Zip

Work Address:                                                                                                                                                        

                                                No. & Street                                           City                         State                       Zip

Home Phone:(          )                                                           Work Phone: (           )                                              

Employer:                                                                 Occupation:                                                                        

Are you now or have you been under the care of a physician within the last two years?                      

If yes, please provide Physician’s Name, address and phone number.                                                                                                                                                                                                                                              

Person to contact in an emergency:                                                                                                                    

Name                                                                                                                                     

 Address & Phone No.                                                                                           

List all medications you are currently taking, including Retin A, Glycolic Acid and Acutane:

List any drug,  makeup, skin or food allergies (i.e., soaps or cleansing creams):                                     

Have you recently undergone a skin peel?                                                                                                       

What products do you use for skin care?                                                                                                          

Do you have or have you had any of the following conditions (answer Yes or No):

_________ Abnormal Heart Condition

_________ Cold Sores

_________ Herpes Simplex

_________ Hemophilia

_________ High or Low Blood Pressure

_________ Prolonged Bleeding

_________ Circulatory Problems

_________ Epilepsy

_________ Diabetes

_________ Fainting Spells/Dizziness

_________ Cataracts

_________ Glaucoma

_________ “Dry Eye”

_________ Corneal Abrasions

_________ Eye Surgery or Injury

_________ Blepharoplasty (eyelid surgery)

_________ Visual Disturbances

_________ Cancer

_________ Tumors/Growths/Cysts

_________ Chemotherapy/Radiation

_________ Are you pregnant?

_________ Hepatitis

_________ Do you wear contact lenses?

_________ Do you use tobacco products?

_________ Are you using any eye drops or other ocular medications?

_________  Have you ever experienced hyper-pigmentation from an injury?

_________  Are you currently taking aspirin or ibuprofen?

When was your last eye exam? ____/____/____

Examining Physician: ___________________________________________________________

Signature                                                                                            Date