Patient Information

Medical History Form

To comply with medical record requirements, please complete the following information using the form below or by downloading the printable PDF and submit to the Illinois Eye Institute:

Patient Info

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should we ABC this???

What is the reason for today's eye exam? (check all that apply):

Blue at Distance

Blue at Near

Double Vision

Dry Eyes

Headache

Glaucoma

Lazy Eye

Red Eyes

Flashes / Spots

Tears / Discharge

Eye Pain / Discomfort

Itching

Broken Glasses

Cataracts

Macular Degeneration

Have you had an eye injury?

Have you had an eye surgery?

Diagnostic Testing

Do you have, or have you been treated for: (check all that apply)

Diabetes (high sugar)

Kidney / Urinary

Sinus / Allergy

Stomach Problems

Headache

Thyroid / Glands

Arthritis / Joint Pain

Depression / Anxiety

Stroke

HIV

STD

Heart Disease

Cancer

Hearing Loss

Skin Condition

Other Reason

Breathing Problems

Do you take any eyedrops?

Do you take any medications?

Do you have any allergies?

Are you pregnant?

Do you smoke?

Did you drink alcohol?

Do you have a history of recreational drug use?

High Blood Pressure

Sickle Cell Disease

Macular Degeneration

Crossed Eyes

Please mark the people in your family who have the following medical problems:

Breathing Problems

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Diabetes (high sugar)

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Arthritis

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Glaucoma

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Blindness

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Retinal Disease

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We pledge to be compassionate, timely, and accessible to you.
We are committed to providing excellent and customized service to you.

Thank you for choosing and trusting the Illinois Eye Institute. We look forward to sharing in the eye care.

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3241 S. Michigan Ave.

Chicago, IL 60616

312.225.6200

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8:00 a.m.  -  4:30 p.m.

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