Maple Grove Eye Clinic and Opticians is your Competent Caring Professional conveniently located in downtown Maple Grove, MN

Medical Information Form

We would appreciate it if you would take the time to fill out this form as well as the General Information Form as completely as possible before your visit. This will reduce the amount of time required in the office. Thank you.

Date (MM/DD/YYYY):
Name:
Age:
Date of Birth (MM/DD/YYYY):
SSN:
Email Address:
Cardiovascular:	None Hypertension Stroke Heart Disease Vascular Disease Other:
Constituitional:	None Cancer Trauma/Large Volume Blood Loss Developmental Disability Other:
Neurological:	None Multiple Sclerosis Epilepsy Cerebral Palsy Tumor Other:
Hematological:	None Anemia Leukemia Other:
Dermatologic:	None Eczema Rosacea Psoriasis Other:
Endocrine:	None Non-insulin Dependent Diabetes Insulin Dependent Diabetes Thyroid Problems Hormonal Dysfunction Other:
Genitourinary:	None Kidney Disease Urinary Tract Infection STD-Herpetic/Chlamydia Other:
Musculoskeletal:	None Osteoarthritis Fibromyalgia Muscular Dystrophy Ankosing Spondylitis Other:
Gastrointestinal:	None Crohn's Colitis Other:
Drug Allergies (Please List):
Environmental Allergies (Please List):
Respiratory:	None Asthma Bronchitis Emphysema COPD Other:
Psychiatric:	None ADHD Depression Schizophrenia Other:
Immuniologic:	None AIDS or HIV Rheumatiod Arthritis Lupus Neurofibromatosis Other:
Ear/Nose/Throat:	None Hearing Loss Upper Respiratory Infection Other:
Alcohol Use?:	YesNo
Alcohol Use Amount:
Tobacco Use?:	YesNo
Tobacco Use Amount:
Please list any medications that you are taking (including herbal) that are not listed above:
What prompted your visit with us today?
Are you experiencing any of these symptoms?:	BLUR AT FAR BLUR AT NEAR EYE STRAIN POOR NIGHT VISION BURNING EYES ITCHY EYES DRY EYES WATERY EYES LIGHT SENSITIVE FLOATERS/SPOTS HEADACHES MIGRAINES Other:
Any changes in family history?: