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Dr. Michael Schall
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2017-07-06T01:14:32+00:00
Dr. Michael Schall
Patient Demographics
Name
*
First
Middle
Last
Date of Birth
MM slash DD slash YYYY
SSN
Marital Status
Single
Domestic Partner
Married
Divorced
Widowed
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
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Virgin Islands, U.S.
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Country
Email
Home Phone
Cell Phone
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Employment
Full Time
Part Time
Retired
Student
Employer (if applicable)
Vision Insurance
Blue Choice
Davis Vision
EyeMed
Medicaid
Spectera
Superior Vision
Tricare Prime
United Healthcare Vision
VSP
Other
Member ID#
Medical History
Date of Last Eye Exam
MM slash DD slash YYYY
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.
Blindness
Cataracts
Crossed Eyes
Glaucoma
Macular Degeneration
Retinal Detachment
High Blood Pressure
Kidney Disease
Diabetes
Heart Disease
Arthritis
Lupus
Thyroid Disease
Cancer
Other
None of the above
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
Loss of Vision
Blurred Vision
Distorted Vision/Halos
Loss of Side Vision
Double Vision
Dryness
Mucous Discharge
Redness
Sandy or Gritty Feeling
Itching
Burning
Foreign Body Sensation
Excess Tearing/Watering
Glare Light Sensitivity
Eye Pain or Soreness
Chronic Infection of Eye or Lid
Sties or Chalazion
Flashes/Floaters in Vision
Tired 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
MM slash DD slash YYYY
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