New Patient Health History Form

Name*

Email *

Phone *

Personal Medical History (New Patient) Review of Systems:

Please check if any of the following applies to you, past or present:

If Other, Please state

Hemotological

None Anemia Leukemia Other

If Other, Please state

Gastrointestinal

None Crohn's Disease Colitis Other

If Other, Please state

Ear/Nose/Throat

None Hearing Loss Upper Respiratory Infection Other

If Other, Please state

Allergies

None Drug/Medication Environmental Other

If Other, Please state

Please list any physical reaction to any medication allergies

Alcohol Use?

Yes No

Amount

Tobacco Use?

Current Past Never

Type

Amount

Number of Years

Have you ever been treated with oral prednisone?

Yes No

Please list any Medication that you are taking

Family History

Has anyone in your immediate family (Grandparents, Parents, Siblings, Children, Living or Deceased - Please note maternal or Paternal) been diagnosed with:

Disease/Condition

Yes No

Relationship

Cataracts

Yes No

Relationship

Glaucoma

Yes No

Relationship

Crossed Eyes

Yes No

Relationship

Macular Degeneration

Yes No

Relationship

Retinal Detachment

Yes No

Relationship

Hypertension

Yes No

Relationship

Diabetes

Yes No

Relationship

Heart Disease

Yes No

Relationship

Thyroid

Yes No

Relationship

Cancer (Include Type)

Yes No

Relationship

Please do not submit any Protected Health Information (PHI).

Location

Find us on the map

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Spearfish Eye Care Center

Address

1710 North Ave
Spearfish, South Dakota 57783, US

Contact Information (605) 642-8480

(605) 642-8185

[email protected]

Hours of Operation

Spearfish Eye Care Center

Monday

8:00 am - 5:30 pm

Tuesday

8:00 am - 5:30 pm

Wednesday

8:00 am - 5:30 pm

Thursday

8:00 am - 5:30 pm

Friday

8:00 am - 5:30 pm

Saturday

Closed

Sunday

Closed