PATIENT MEDICAL HISTORY
This information is confidential and is for medical records only
Patient Name
Address where patient resides
Date of Birth
Date
Phone
E-mail
Sex Male Female
Work/Cell
Marital Status
Please keep me updated with current MEI Promotions, special offers and Institute news___________(please initial)
COMPLETE THIS AREA IF UNDER 18 YEARS OF AGE
Father/Guardian Name Mother/Guardian Name
Address
Phone Work/Cell
Address
Phone Work/Cell
EMERGENCY CONTACT INFORMATION
Emergency contact
(not living with you)
Family Physician or Internist
Relationship
Phone
Referring Doctor
Medications Eye Medications
Name Dose Times Per Day Name Times Per Day RT LT
Do you take aspirin on a daily basis?
YES
NO
List any medications you are allergic to
Name of Pharmacy
Street Address City State ZIP
(If your pharmacy has more than one location in the same city, please provide exact street address, if known)
Telephone
Milauskas
Eye
Institute
What prior surgeries have you had?
Ocular History
Active or past history of any eye condition such as glaucoma, cataracts, keratoconus, injuries or amblyopia?
Prior eye surgeries including laser procedures:
Do you wear glasses?
Do you wear contact lenses?
Yes
Yes
No
No
If yes, how old are they?
If yes, how old are they?
