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Patient Health

Please fill out the form below and click "submit".

Patient Name: *
 
Date: *
 
What is your main reason for coming for an eye exam?: *
 
What is the date of your last exam (N/A if done at Eccarius Eye Clinic)?: *
 
When did you last change your glasses, and who prescribed them (N/A if Dr. Eccarius prescribed them)?: *
 
List any allergies you have:
List the medications you are currently taking:
Have you ever had any eye injuries, surgeries, or diseases?:
Ophthalmology is a specialized area of medical practice. This information is important for Dr. Eccarius to perform a thorough examination. Thank you for answering the following questions:
Do you have / have you had (please check all that apply):



















































Do you use:

Have you ever:






Has anyone in your family had:



Please list any drug allergies you have: