Patient Health History

Thank you for choosing our practice.
To better serve you, please fill out the information below to the best of your ability.

* - required

Eye History

Medical History

Do you have or have you ever had:


Please list ALL medications you are currently taking,
including over-the-counter, prescriptions, and vitamins:

Medication Dosage Times Per Day

Review of Symptoms

Are you currently experiencing problems with any of the following?

Social History

Family History

Family Relation Medical/Eye Disease If deceased, cause of death

To the best of my knowledge, the questions on this form have been accurately answered. It is my responsibility to inform Dr. Saunders' office of any changes in my medical status.