Medical History

Patient Medical History

Do you currently wear:

Glasses
Contact Lenses
Low Vision Aids
Do you currently have or have you ever had any of the following:
Eye Surgeries
Eye Injuries
Eye Infections
Amblyopia
Cataracts
Dry Eyes
Light Sensitivity
Pain
Glaucoma
Lazy Eye
Macular Degeneration
Eye Turn In / Out
Reading Problems
Tracking Problems
Other
Do you Have:
Diabetes
Headaches
Medication - List any Medications:

Are you currently taking prescription or non-prescription drugs?
Allergies - List any known Allergies:

Do you currently have any Allergies known or perceived?
Do you have problems with any of these systems? - Please check all that apply
Allergic / Immunologic
Arthritis
Blood / Lymph
Cardiovascular Heart Disease
Ear / Nose / Throat
Endocrine Glands
Gastrointestinal
Integument Skin
Kidney Problems
Musculature
Nervous
Psychiatric
Respiratory
Skeletal Bones
Thyroid Problems
Other (explain bottom of page)
Do you use - Please select all that apply
Cigarettes?
Alcohol?
Other substances?
Family Eye History - Anyone in patient's family (blood relative) had any of the following?
Cataracts
Cornea Disease
Diabetes
Glaucoma
Lazy Eye
Macular Degeneration
Retina Disease
High Blood Pressure
Other Eye Disorders
Your Surgical History- List any type of surgery and dates of surgery
Occupation- If applicable, what type of work do you do?
Hobbies- List any hobbies or sports you participate in
LASER VISION CORRECTION
CONTACT LENSES
EYEGLASSES
SUNGLASSES
CHILDREN'S VISION
Other Information- Please elaborate on any information or from any "Other" box above.

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forsight eye center

Dr. Thao Truong, Optometrist and
Dr. John Barker, Optometrist
Your Eye Doctors in Cumming, GA

Office Address: 975 Peachtree Parkway Suite A Cumming, GA 30041
Phone: (678) 208-2375
Fax: (678) 208-2379

Hours of operation

Monday8:30AM - 5:00PM
Tuesday8:30AM - 1:00PM
Wednesday8:30AM - 5:00PM
Thursday8:30AM - 5:00PM
Friday8:30AM - 1:00PM
WeekendClosed
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