Medical History Questionnaire Please enable JavaScript in your browser to complete this form.Select Office LocationOffice Location *New BerlinBrookfieldPatient InformationName *FirstMiddleLastAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDaytime Phone *Cell PhoneEmail *S.S.N. (last 4 digits only!)Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender *FemaleMaleParent/Guardian Name (if minor)FirstLastOccupation/School Grade (if minor) EmployerSpouse's NameFirstLastWho is responsible for payment of services rendered?* *PhysicianHealth Insurance and Policy #Date of last eye exam Vision Insurance and Policy #Do you feel that your eyes are changing?YesNoDo you have questions about laser refractive surgery?YesNoDo you currently wear contact lenses?YesNoIf yes, what type?Soft DisposableRigid Gas PermeableDo you experience any of the following with your vision? Please mark all that apply.Blurred distanceBlurred nearBurningItchinessHeadachesTearingDrynessEye strainReading problemsFloaters/SpotsSorenessFlashes of lightRednessDouble visionSudden loss of visionSensitivity to lightHow did you hear about our office?FriendRelativeInsuranceOtherMedical HistoryList ALL medications that you are currently taking (include oral contraceptives, OTC medications, vitamins, home remedies or eye drops):Do you have any allergies to medications?*YesNoDo you use tobacco products?YesNoDo you drink alcohol?YesNoEye HistoryDo you have, or have you had in the past any of the following: Please mark all that apply.GlaucomaEye InjuryEye SurgeryCataractsEye InfectionLazy EyeEye DiseaseOtherFamily Eye HistoryDisease/ConditionGlaucomaCataractsDiabetesHypertensionLazy EyeMacular DegenerationOther eye problemsPlease note relationship (parent, grandparent, sibling, child, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.If Other, please explain:If any of the above are marked, please list relationship:REVIEW OF SYSTEMSDo you currently or have you ever had any problems in the following areas?ConstitutionalGood General HealthYesNoRecent Weight ChangeYesNoFever/FatigueYesNoOtherYesNoIf Other, please explain:Nervous SystemMultiple SclerosisYesNoHead InjuryYesNoSeizures/ConvulsionsYesNoOtherYesNoIf Other, please explain:EndocrineDiabetesYesNoThyroidYesNoMenopauseYesNoOtherYesNoIf Other, please explain:Ear/Nose/ThroatSinusYesNoHearing LossYesNoSore ThroatYesNoOtherYesNoIf Other, please explain:RespiratoryAsthmaYesNoBronchitisYesNoEmphysemaYesNoOtherYesNoIf Other, please explain:CardiovascularHeart DiseaseYesNoHigh Blood PressureYesNoStrokeYesNoOtherYesNoIf Other, please explain:GastrointestinalColitis/Crohn'sYesNoUlcersYesNoRefluxYesNoOtherYesNoIf Other, please explain:GenitourinaryKidney ProblemsYesNoProstateYesNoOtherYesNoIf Other, please explain:MusculoskeletalOsteoarthritisYesNoFibromyalgiaYesNoCold ExtremitiesYesNoOtherYesNoIf Other, please explain:SkinEczemaYesNoRosaceaYesNoPsoriasisYesNoOtherYesNoIf Other, please explain:Blood/LymphAnemiaYesNoLarge Blood LossYesNoBleeding DisorderYesNoOtherYesNoIf Other, please explain:Immune/AllergyEnvironmental AllergyYesNoRheumatoid ArthritisYesNoLupusYesNoOtherYesNoIf Other, please explain: PsychiatricDepressionYesNoMemory Loss/ConfusionYesNoSchizophreniaYesNoOtherYesNoIf other, please explain:OtherCancerYesNoDevelopmental DisorderYesNoLoss of ConsciousnessYesNoOtherYesNoIf Other, please explain:Privacy PolicyHealth Information Protection *I have read and agree to the Privacy PolicySignature * Clear Signature Date *Submit Our Office 15441 W National AveNew Berlin, WI, 53151 Get Directions Phone: 262-789-6929 Email: newberlin@eyesite-vision.com Follow Write a Review! Business Hours (closed daily between 1:00 PM - 2:00 PM for lunch) Monday:9:00 AM to 7:00 PM Tuesday, Wednesday & Thursday9:00 AM - 6:00 PM Friday:8:00 AM to 5:00 PM Saturday:9:00 AM to 1:00 PM Sunday:Closed
