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Announcing the BC Young Optometrist of the Year: Dr. Sophia Capo. Read More

Absee Optometry and Vision Therapy's reception area features a wooden counter, gray walls, and a sign with an eye icon, surrounded by a serene and welcoming atmosphere.

Medical History Form

Please complete the information below and submit the form online or, if you prefer, print out the form after full or partial completion and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Thanks for contacting us! We will get in touch with you shortly.

Patient Information

Today's Date *
Name *
Address *
*
Date of Birth *
Date of Last Medical Exam *
Date of Last Eye Exam *

Medical History

Check any of the following that you have had:
Are you pregnant or nursing?
Do you wear glasses?
Do you wear glasses?

Family History

Note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.

Check any of the following that you have had:

Social History

Do you drive?
Do you use tobacco products?
Do you drink alcohol?
Do you use illegal drugs?
Have you ever been exposed to or infected with:

Review of Systems

Do you currently or have you ever had any problems in the following areas?

Constitutional
Endocrine
Gastrointestinal
Neurological
Ears, Nose, Mouth, Throat
Respiratory
Vascular/Cardiovascular
Eyes
Genitourinary
Lymphatic/Hematologic
Allergic/Immunologic
Psychiatric

If you answered Yes to any of the above review of systems questions or have a condition not listed, please explain and list any related medications when you meet with your doctor.

Please provide your Patient Signature and Date at the time of submission.

For questions, please contact us at 236-420-7222.

*
Date Signed *
A B See Optometry and Vision Therapy
monday:
8:00 am - 4:00 pm
tuesday:
8:00 am - 4:00 pm
wednesday:
8:00 am - 4:00 pm
thursday:
8:00 am - 4:00 pm
friday:
8:00 am - 4:00 pm
saturday:
Closed
sunday:
Closed