Health Questionnaire

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Patient History and General Health Questionnaire

Patient Name: ___________________________________ Date: _______________________ At your initial visit, it is valuable to have a summary letter or copies of your ophthalmologist’s office records and any other relevant photographs or test (examples: fluorescein angiogram, visual field, CT/MRI scans, or contact lens information). We suggest that these records be brought in person rather than mailed to ensure that they are present at your examination with us. Having this information will help to make your eye evaluation as thorough and complete as possible. Please contact your ophthalmologist’s office directly for this purpose.

We need you to complete the following information as thorough as possible to ensure that your care is of the highest quality. Bring this completed form with you to your appointment. If you wear glasses, be sure to bring them as well. THANK YOU! We look forward to serving you.

What medications do you take? Please list with name and dose. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Do you have allergies to medications? Please list them. __________________________________________________________________________________________________ __________________________________________________________________________________________________ Your referring ophthalmologist or physician name, address, phone: __________________________________________________________________________________________________ General M.D./ Primary Care Provider (name, address, and phone): __________________________________________________________________________________________________ Other doctors you wish us to include (name, address, and phone): __________________________________________________________________________________________________ Please list the person(s) that this office is authorized to discuss/disclose medical information about your exam/ treatment to: __________________________________________________________________________________________________

770 Pine Street ∙Suite 500 ∙ Macon, GA 31204 ∙ Phone: 478-633-8033 ∙ Fax: 478-633-8039 Ophthalmology, NHPG Revised 07/2017 Revision 001