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
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
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.