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- Your Newnan Eye Doctor
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FAQ

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37 Calumet Parkway Building M, Suite 100 Newnan, GA 30263

Call or Text 678-818-4400

Hours & Location
Our Practice
- Your Newnan Eye Doctor
Eye Care Services
Contact Lenses
Insurance Info
FAQ

Hours & Location
Our Practice
- Your Newnan Eye Doctor
Eye Care Services
Contact Lenses
Insurance Info
FAQ

Home » Patient History Form

Patient History Form

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Today's Date*
MM slash DD slash YYYY
Home Phone
Work/Cell Phone
Last Exam Date*
MM slash DD slash YYYY
By Whom*
Birth Date*
MM slash DD slash YYYY
Name of Medical Doctor*
Personal Email*
Employer/Occupation
How did you hear about our office?
Medical History
Do you have any allergies to medications?*
- Yes
- No
If yes, explain
List any medications you take
(including oral contraceptives, eye drops, over the counter medications and home remedies)
List all major injuries, surgeries and/or hospitalizations you have had
(including eyes or vision correction surgery)
Check off any of the following that you have had
- Crossed Eyes
- Lazy Eye
- Drooping Eyelid
- Prominent Eyes
- Glaucoma
- Retinal Disease
- Cataracts
- Eye Infections/Injury
Do you wear glasses?*
- Yes
- No
If yes, how old is your present pair of glasses?*
Would you like to be fit for contact lenses?*
- Yes
- No
Do you wear contact lenses?*
- Yes
- No
If yes, how old is your present pair of lenses?*
Type of contact lenses*
- Rigid
- Soft
Brand*
Solution*
Do you sleep in your contacts?*
- Yes
- No
Avg. # days before removal/cleaning*
Avg. # days before disposing*
Family History
Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions (not including you):
Glaucoma*
- Yes
- No
Relationship to You
Macular Degeneration*
- Yes
- No
Relationship to You
Retinal Disease*
- Yes
- No
Relationship to You
Blindness*
- Yes
- No
Relationship to You
Cataract(s)*
- Yes
- No
Relationship to You
Arthritis*
- Yes
- No
Relationship to You
Cancer*
- Yes
- No
Relationship to You
Diabetes*
- Yes
- No
Relationship to You
Heart Disease*
- Yes
- No
Relationship to You
High Blood Pressure*
- Yes
- No
Relationship to You
Thyroid Disorder*
- Yes
- No
Relationship to You
Other Heritable Disease*
- Yes
- No
Relationship to You
Social History
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
Does your vision limit your ability to drive?
- Yes
- No
Do you use tobacco products?
- Yes
- No
If yes, type/amount/how long
Do you drink alcohol?
- Yes
- No
If yes, type/amount/how long
Review of Systems
Do you currently, or have you ever had, any problems in the following areas:
Eyes*
(loss of vision, blurred vision, distorted vision/halos, sandy or gritty feeling, tired eyes, double vision, dryness, mucous drainage, redness, burning, itching, foreign body sensation, eye pain, soreness, chronic infection, excessive tearing/watering, styes, flashes or floaters in vision)
- Yes
- No
Please specify which condition from the list and explain/give details:
Allergy/Immunologic*
(herpes, hay fever, lupus)
- Yes
- No
Please specify which condition from the list and explain/give details:
Bones/Joints/Muscles*
(rheumatoid arthritis, joint pain, osteoporosis, osteoarthritis)
- Yes
- No
Please specify which condition from the list and explain/give details:
Constitutional*
(fever, fatigue, weight loss/gain, sleep problems)
- Yes
- No
Please specify which condition from the list and explain/give details:
Ears, Nose, Mouth, Throat*
(allergies/hay fever, hearing loss, sinus congestion, post-nasal drip, dry throat/mouth)
- Yes
- No
Please specify which condition from the list and explain/give details:
Endocrine*
(diabetes, thyroid/other glands)
- Yes
- No
Please specify which condition from the list and explain/give details:
Gastrointestinal*
(acid reflux, diarrhea, constipation, hepatitis, gallbladder disorder)
- Yes
- No
Please specify which condition from the list and explain/give details:
Genitourinary*
(kidney stones, incontinence, prostate disorder)
- Yes
- No
Please specify which condition from the list and explain/give details:
Integumentary*
(skin, acne, psoriasis)
- Yes
- No
Please specify which condition from the list and explain/give details:
Lymphatic/Hematologic*
(anemia, bleeding problems)
- Yes
- No
Please specify which condition from the list and explain/give details:
Neurological*
(headaches, migraines, seizures, Bell’s Palsy)
- Yes
- No
Please specify which condition from the list and explain/give details:
Psychiatric*
(anxiety, depression, ADD, Alzheimers)
- Yes
- No
Please specify which condition from the list and explain/give details:
Respiratory*
(asthma, chronic bronchitis, emphysema)
- Yes
- No
Please specify which condition from the list and explain/give details:
Vascular/Cardiovascular*
(elevated cholesterol, heart attack, Heart pain, high blood pressure, stroke, vascular disease)
- Yes
- No
Please specify which condition from the list and explain/give details:
Females*
Are you pregnant or nursing?
- Yes
- No
If you answered YES to any of the above or have a condition not listed, please explain and list medications:
Patient’s Signature*
Date*
MM slash DD slash YYYY

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37 Calumet Parkway Building M, Suite 100

Phone: (678) 818-4400
Text: (678) 818-4400
Fax: (678) 224-8594

37 Calumet Parkway, Building M, Suite 100
Newnan, GA 30263

Monday: 9:00 AM - 5:00 PM
Tuesday: 9:00 AM - 5:00 PM
Wednesday: 9:00 AM - 5:00 PM
Thursday: 9:00 AM - 5:00 PM
Friday: 9:00 AM - 2:00 PM
Saturday: Closed
Sunday: Closed

*Closed daily from 1pm - 2pm for lunch

For medical emergencies after hours, please contact Omni Eye Services at (770) 996-6664.

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37 Calumet Parkway Building M, Suite 100

37 Calumet Parkway, Building M, Suite 100
Newnan, GA 30263

Phone: (678) 818-4400
Text: (678) 818-4400
Fax: (678) 224-8594

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