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:

Download Printable Form (PDF)

Patient Info

should we ABC this???

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)

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

Diabetes (high sugar)

Arthritis

Glaucoma

Blindness

Retinal Disease

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.