Medical History Questionnaire

So the we may serve you more efficiently and effectively, please fill out the forms below prior to your appointment. This page is best viewed on a desktop, laptop, or tablet. Your information is submitted securely and will not be shared with anyone. Thank You.

Fields marked with an asterisk (*) are required.

If you do not yet have an appointment, please call our office at (713) 664-4760 or use our online Appointment Request Form to schedule an appointment before submitting your information to us.

Medical History / General Health Questionnaire

Gender *

Are you a student?

Is the patient the responsible party? *

Is there anyone else we should contact in case of emergency? *

Do you have insurance? *

The following questions about your lifestyle, ethnic origin, general health. and medications (prescriptions, vitamins, holistic, and OTC) can have important inter-relationships with the condition of your eyes and your prescribed eye care. Your answers are kept strictly confidential.

Are you currently taking any prescription or over-the-counter medications? *

Do you have any allergies? *

Do you currently wear glasses? (Check all that apply) *

What type of glasses do you own? (Check all that apply) *

Please check all the conditions that apply to you. A check indicates 'Yes'. *

Do you suffer from any of the following? Please check all that apply. *

Do you currently wear contact lenses? *

Have you ever tried wearing contact lenses and stopped? *

Are you interested in using contact lenses to change or enhance your eye color?*

If you wear contact lenses do your backup glasses have your current prescription? *

Have you ever had an injury to either of your eyes? *

Would you like to be evaluated for refractive laser (LASIK) surgery? *

Would you like to be evaluated for non-surgical vision correction? *

Do we have your permission to email you on your birthday and occasionally to keep you informed of the latest news in eye health? *

6 + 5 =

Contact Details

*Please list all insurances, both vision and medical in the designated areas and please remember to bring all insurance cards with you to your appointment. The social security number of the policyholder is not a requirement for the completion of this form but it will be necessary to verify insurance coverage. If you would rather give us that information by phone, please call us at 770-939-8840 and ask for the appointment desk.

770-939-8840

contactus@georgiaeyecenter.net

4135 Lavista Rd Ste 100 Tucker, GA 30084

The Georgia Eye Center is conveniently located on Lavista Road In Tucker, Georgia in the Northlake Square plaza. We are very convenient to I-285 and there is plenty of available parking.

Dr. Kyle Jones

Georgia Eye Center