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2. How did you learn about our practice?

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3. Whom may we thank for referring you?

4. Current or Past Medical History

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5. Are you currently:

Pregnancy / Nursing Status

6. Medications

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10. Eye History

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11. Social History

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12. Family History

Check the box if any of your relatives, living or deceased, had any problems with the following conditions. For each condition, please indicate which family member(s): Father, Mother, Sibling, Child, Unknown, or None.
Arthritis — family members affected:
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13. Insurance

14–22. COVID-19 Screening

14. Do you have a cough?
15. Do you have a fever now or have you in the past 14–21 days?
16. Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?
17. Are you experiencing shortness of breath or difficulty breathing?
18. Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
19. Have you experienced recent loss of taste or smell?
20. Are you over the age of 60?
21. Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?
22. Have you traveled in the last 14 days to any regions affected by COVID-19?
By submitting this form, I agree that I have read and understand the above and have voluntarily answered all questions truthfully and to the best of my ability.
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