Home
New Patient Center
- Patient Info & Forms
Contact Us
- Appointment Request
- Prescription Refill Request
About Us
Conditions Treated
Services
Resources
- Privacy Practices
- No Show Policy
FAQ’s
Articles

(812) 339-7995 Schedule Appointment

Home
New Patient Center
- Patient Info & Forms
Contact Us
- Appointment Request
- Prescription Refill Request
About Us
Conditions Treated
Services
Resources
- Privacy Practices
- No Show Policy
FAQ’s
Articles

(812) 339-7995 Schedule Appointment

Home

Patient Form 1

Patient Form 1

Name*

Date of birth

Today's Date

Email *

Phone *

MEDICAL HISTORY – Do you have any of the following?

High Blood Pressure

Yes No

# of Years

Diabetes

Yes No

# of Years

Cancer

Yes No

Heart Disease

Yes No

Breathing Problems

Yes No

Kidney Disease

Yes No

Circulation Problems

Yes No

Ear/Nose/Throat

Yes No

Stomach Problems

Yes No

Neurological Disorders

Yes No

Psychiatric Disorder

Yes No

Skin Disorders

Yes No

Allergic / Immune

Yes No

Thyroid

Yes No

Migraines / Headaches

Yes No

Muscle / Skeletal

Yes No

Other

Do you smoke?

Yes No

# packs/day

Do you drink alcohol?

Yes No

# drinks/day

Do you live alone?

Yes No

FAMILY / MEDICAL DOCTOR(S)

PHONE

SURGICAL / HOSPITALIZATION HISTORY (within the last 10 years) – Please include dates:

MEDICATION HISTORY – Please list all medication you are currently taking (include dossage):

PLEASE LIST ALL MEDICATION YOU ARE ALLERGIC TO

ARE YOU ALLERGIC TO THE FOLLOWING ITEMS

LATEX RUBBER EGGS SOYBEANS PEANUTS

OTHER

OCULAR HISTORY – Have you been diganosed with any of the following in the past?

Cataracts

Yes No

Retinal Disorder

Yes No

Crossed Eyes

Yes No

Corneal Disease

Yes No

Glaucoma

Yes No

Injury

Yes No

Eye Surgery

Yes No

Other Eye Disorders

Yes No

Specify

FAMILY HISTORY – Has anyone in your family had any of the following? Please note relation to patient:

Cataract