Patient History Form Name First Last DATE OF BIRTH MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country FAMILY DR HEALTH CARD #PATIENT'S OCCUPATION: (If Student what Grade?) PHONE #:HomeBusinessOther Insurance Name: Policy NumberCertificate ID PARENT/GUARDIAN (IF CHILD IS THE PATIENT) Email (E-mail addresses will not be given out to 3rd parties.) I authorize consent to use my e-mail address for communication and verification. (E-mail addresses will not be given out to 3rd parties.) FAMILY & PERSONAL HISTORYCheck ALL that apply: SELF Allergies Arthritis Asthma Blindness Cancer Cataracts Colour Deficiency Crossed/Lazy Eye Diabetes Glaucoma High Blood Pressure High Cholesterol HIV/Hepatitis Macular Degeneration Neuromuscular Problems Retinal Detachment Stroke Thyroid Condition Tuberculosis FAMILY Allergies Arthritis Asthma Blindness Cancer Cataracts Colour Deficiency Crossed/Lazy Eye Diabetes Glaucoma High Blood Pressure High Cholesterol HIV/Hepatitis Macular Degeneration Neuromuscular Problems Retinal Detachment Stroke Thyroid Condition Tuberculosis PROBLEMS Blurry Distance Vision Blurry Near Vision Burning Eyes Dark spots in vision Discharge/Watery Discomfort in brightness and sunlight Double Vision Eye Injury Eye Strain Flashes of Light Floaters/spots in vision Glare/Reflections/Halo's Headaches History of Eye Surgery History of wearing Eye Patch Itchy Eyes Poor Night Vision Rainbows around Lights Red Eyes Sandy/Dry eyes Trouble Reading INTERESTS New Glasses / Brands Contact Lenses Dry Eye Therapy Durability Laser Eye Surgery/ LASIK Light Weight Glasses Safety Glasses Sunglasses How were you Referred Another Patient Bus Stop at Rymal Road Drive By Facebook Family Doctor Flyers Glanbrook Gazette Google Lawn Sign Presencia Latina The Sachem Latino Newspaper Previous Burl PX Eye See Eye Learn Other ( Please Specify ) (Please Specify) I give consent for my Personal/Clinical information to be used by Dr. Garzon and Staff for any Eye Care services provided at this office. SignatureDate MM slash DD slash YYYY