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Liverpool: (315) 325-2020

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Fayetteville: (315) 625-2020

Book Appointment!

Liverpool: (315) 325-2020

Book Appointment!

Fayetteville: (315) 625-2020

Book Appointment!

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Home » Patient History Form

Patient History Form

For a printable form click here

ATTENTION: All information given is confidential and HIPAA protected. Please note that in order for the doctor to provide a comprehensive eye exam all of this medical information is necessary and will save you time on your appointment.

Step 1 of 5

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Demographics
Location*
Today's Date:*
MM
DD
YYYY
Full Name:*
Gender:*
- M
- F
Birth Date:*
MM
DD
YYYY
Title:*
- Mr.
- Mrs.
- Miss
- Ms.
- Dr.
Marital Status:*
- Single
- Married
- Widowed
- Divorced
- Separated
Address:*
Street Address Address Line 2 City State ZIP Code
Email:*
Last 4 digits of Social Security #:*
Home Phone:*
Cell Phone:
Texting*
- Y
- N
Communication Preference:*
- Email
- Postal
- Phone
Responsible Party if different:
Billing Address if different:
Street Address Address Line 2 City State ZIP Code
Phone:
Relationship to patient:
Medical Insurance:
Vision Insurance:
Place of Employment:
Work Phone:
If Married, Name of Spouse:
Spouse’s place of work:
Name of Medical Doctor:*
Phone:
Pharmacy:
Pharmacy Phone:
Pharmacy Address:
Street Address Address Line 2 City State ZIP Code
Name of Previous Eye Doctor:
Whom may we thank for referring you:
*** PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED***
We accept Visa, MasterCard, Discover, American Express, Care Credit, and Debit Cards

Ocular / Medical History
Do you wear glasses?*
- No
- Yes
How old are your eyeglasses?*
Are you getting glasses today?*
- No
- Yes
Do you wear contact lenses?*
- No
- Yes
If yes, what type?*
- RGP
- Soft
Do you sleep in them?*
- No
- Yes
How frequently do you replace them?*
Solution Brand?*
Are they comfortable?*
- No
- Yes
Are you interested in contact lenses today?*
- No
- Yes
Do you wear Safety Glasses for home/work?*
- No
- Yes
Are you currently experiencing any of the following problems with your eyes?
Check the box if “Yes.”
- Blurred Vision
- Redness
- Halos / Glare
- Loss of Vision
- Eye Pain or Soreness
- Light Sensitivity
- Flashes
- Dryness
- Floaters
- Excess Tearing / Watering
- Double Vision
- Foreign Body Sensation
- Dizziness
- Burning
- Tired Eyes
- Itching
Have you been diagnosed with any of the following ocular problems?
Check the box if “Yes.”
- Cataracts
- Glaucoma
- Retinal Detachment
- Crossed Eyes
- Lazy Eye
- Drooping eyelid
- Eye Injury
- Macular Degeneration
- Other
If other, please specify:*
Are you taking any medications?*
- No
- Yes
List any medications you are currently taking:*
(include oral contraceptives, aspirin, over the counter, and home remedies)
Are you allergic to any medications?*
- No
- Yes
If yes, please explain:*

Preferred Language:*
- English
- Spanish
Race:*
- Native American/Alaskan
- Asian
- African American
- Hispanic
- Native Hawaiian/Other Pacific Island
- White
Ethnicity:*
- Hispanic/Latino
- Native Hawaiian/Pacific Islander
- Non Hispanic/Latino

Review of Systems
Please check the box beside any problem you currently have in the following areas:
Allergic / Immunologic*
- All Normal
- Allergy / Hayfever
Cardiovascular / Cardiac*
- All Normal
- Arteriosclerosis
- Heart Disease
- High Blood Pressure
- High Cholesterol
Constitutional*
- All Normal
- Fever
- Weight Loss
- Weight Gain
Ears, Nose, Mouth, Throat*
- All Normal
- Sinus Congestion
- Dry Throat / Mouth
Endocrine*
- All Normal
- Diabetes
- Thyroid Disease
- Chronic Fatigue
If diabetes:*
Blood Sugar A1C Years
Gastrointestinal*
- All Normal
- Diarrhea
- Constipation
- Ulcers
- Reflux
Genitourinary*
- All Normal
- Kidney Disease
- Ovarian / Uterine Cancer
- Prostate Cancer
- Polycystic Ovarian Syndrome (PCOS)
Hematologic / Lymphatic*
- All Normal
- Anemia
- Bleeding Problems
- Breast Cancer
Integumentary (Skin)*
- All Normal
- Skin Cancer
- Rashes
- Easy Bruising
Musculoskeletal*
- All Normal
- Rheumatoid Arthritis
- Muscle Pain
- Joint Pain
- Fibromyalgia
- Osteoporosis
Neurological*
- All Normal
- Headaches/Migraines
- Dizziness/Vertigo
- Seizures
- Stroke
Psychiatric*
- All Normal
- Anxiety
- Depression
- Memory Loss
- Hallucinations
- ADD/ADHD
- Autism
- Alzheimer’s
- Dementia
Respiratory*
- All Normal
- Asthma
- Bronchitis
- Emphysema
- Chronic Cough
- COPD
If you checked any of the above boxes or have a condition not listed, please explain further:
Are you pregnant and / or nursing?*
- Yes
- No
Have you had any major surgeries and / or hospitalizations?*
- No
- Yes
List all major surgeries and / or hospitalizations you have had:*

Family History
Please note any family history (parents, grandparents, siblings, children):
Blindness
Relation to You How?
Cataract
Relation to You
Crossed Eyes
Relation to You
Glaucoma
Relation to You
Macular Degeneration
Relation to You
Retinal Detachment
Relation to You
Rheumatoid Arthritis
Relation to You
Cancer
Relation to You
Diabetes
Relation to You
Heart Disease
Relation to You
High Blood Pressure
Relation to You
Kidney Disease
Relation to You
Lupus
Relation to You
Thyroid Disease
Relation to You
Social History
This information is kept strictly confidential. However, you may discuss this portion directly with your doctor if you prefer.
- Please check the box if you wish to discuss your Social History directly with your doctor
Do you drive?*
- Yes
- No
If yes, describe any visual difficulty while driving:
Do you smoke?*
- Yes
- No
- Former Smoker
If you’re a current smoker, for how long? How many years?*
If you’re a former smoker, for how many years were you a smoker?*
When did you quit?*
Do you use tobacco products?*
- Yes
- No
If yes:*
Type Amount (packs) How long (years)
Do you drink alcohol?*
- Yes
- No
If yes:*
Type Amount per day How long Only Social
Do you use illegal drugs?*
- Yes
- No
If yes:*
Type Amount How long
Indicate by checking the box if you have been infected with or exposed to:
- Gonorrhea
- Hepatitis
- HIV
- Syphilis
- MRSA
Signature:*
Date:*

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Liverpool
Fayetteville

VISIT US

Liverpool

Phone: (315) 622-3500
Fax: (315) 622-3522
Email: Liverpool@DrMalara.com
(Do not send personal health information by email.)

Monday: 9:00 AM - 7:00 PM
Tuesday: 9:00 AM - 6:00 PM
Wednesday: 9:00 AM - 7:00 PM
Thursday: 10:00 AM - 6:00 PM
Friday: 9:00 AM - 4:00 PM
Saturday: 9:00 AM - 1:00 PM
Sunday: Closed

Fayetteville

Phone: (315) 445-9856
Fax: (315) 445-9802
Email: Fayetteville@DrMalara.com
(Do not send personal health information by email.)

Monday:9:00 AM - 1:00 PM
Tuesday:9:00 AM - 3:00 PM
Wednesday:9:00 AM - 7:00 PM
Thursday:10:00 AM - 5:00 PM
Friday:CLOSED
Saturday:9:00 AM - 1:00 PM
Sunday:CLOSED

Find Us Here

Malara Eyecare & Eyewear Gallery - Located at 8395 Oswego Rd., Liverpool, NY, 13090. Phone: (315) 622 - 3500. https://www.drmalara.com/

Malara Eyecare & Eyewear Gallery - Located at 6950 E Genesee St., Fayetteville, NY, 13066. Phone: (315) 445 - 9856. https://www.drmalara.com/

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Liverpool
Fayetteville

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