Whether you are a new or existing patient at Community Eye Associates, you can fill out this form to send us your medical history information for your next appointment. If you have any questions, please call us at (336) 983-4313.

If you would rather print out your form, click here for a Word document version.
 

General Medical History
Please check the boxes if you have any of these medical problems:
 
  Patient Name:

Allergies (seasonal or to medications)
 
Please list medications:

Cardiovascular

Diabetes
 
Year of onset:

High Blood Pressure
 
Year of onset:

Cholesterol

Heart Disease

Weight Loss or Gain

Fever

Thyroid

Kidney, Bladder or Irritable Bowel Syndrome

Ears, Nose or Throat

Bleeding Condition or Lymph Condition

Immune System

Cancer
 
Year of onset and location:

Skin

Muscle or Bone Condition

Headache

Seizures

Psychiatric

Asthma

Emphysema

Other:

All Systems Negative


Ocular History
 Please check the boxes if you have any of these ocular conditions:
 

Amblyopia (lazy eye)

Cataracts

Diabetic Retinopathy

Glaucoma

Iritis

Macular Degeneration

Retinal Detachment

Strabismus (crossed eyes)

Other:

Negative Ocular History


Family History
Please check the boxes if any of your family members (parents, grandparents, siblings) has any of these medical conditions and indicate which family member:
 

Diabetes

High Blood Pressure

Heart Disease

Cancer

Glaucoma

Macular Degeneration

Cataracts

Other
Negative Family History  
     

Note: If you have more than one relative
with any of the conditions mentioned above please make us aware by describing the relationship and condition here.


Social History
Please check the boxes if you use any of the following substances:
 

Alcohol

Tobacco

Illegal Drugs

None of the Above Used


Please check the box if you are:
 

Single

Married

Separated

Divorced

Widowed


Current Medications
Please list all medications you are currently taking:

 
 


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