Dr. Michael Schall

Patient Demographics

Name*

First Middle Last

Date of Birth

SSN

Marital Status

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Home Phone

Cell Phone

Work Phone

Employment

Employer (if applicable)

Vision Insurance

Member ID#

Medical History

Date of Last Eye Exam

Last Eye Doctor

Please list any medication allergies:

List any medications you are currently taking:

Have you had any of the following?

Crossed Eyes
Lazy Eye
Drooping Eyelids
Glaucoma
Retinal Disease
Cataracts
Eye Infections
Eye Injury
Other

If yes, please explain.

Are you pregnant or nursing?

Yes
No

Do you wear glasses or contacts?

Glasses
Contacts
Neither

How old are your current lenses (glasses)?

How old are your current lenses (contacts)?

What brand are your contacts?

Are your contacts comfortable?

Do you sleep in your contacts?

Family History

Please check all conditions that are in your family history.

Relationship of Affected Family Member(s):

Social History

This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.

Do you have difficulty driving?

Yes
No

Please Explain:

Do you use tobacco products?

Yes
No

Type/Amount/How long?

Do you use alcohol?

Yes
No

How many drinks per week?

Do you use illegal drugs?

Yes
No

Type/Amount/How long?

Review of Systems

Do you currently or have you ever had any (chronic) problems in the following areas?

Constitutional

Fever
Weight Loss
Weight Gain

Neurological

Headaches
Migraines
Seizures

Eyes

Endocrine

Thyroid
Other Glands

Ear, Nose, Mouth, Throat

Allergies/Hay Fever
Sinus Congesion
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Throat/Mouth

Respiratory

Asthma
Chronic Bronchitis
Emphysema

Vascular/Cardiovascular

Diabetes
Heart Pain
High Blood Pressure
Vascular Disease

Gastrointestinal

Diarrhea
Constipation

Genitourinary

Genitals
Kidney
Bladder

Bones/Joints/Muscles

Rheumatoid Arthritis
Muscle Pain
Joint Pain

Lymphatic/Hematologic

Anemia
Bleeding Problems

Other

Allergic/Immunologic
Psychiatric
Skin

If you checked any of the above or have a condition not listed, please explain and list medications:

Signature

Date