Medical history

Please complete this form in preparation for your appointment.

Full Name (Patient)*

Date of birth*

Have you seen Dr Laithwaite before?

No
Yes - at Blairgowrie
Yes - at Northcliff Eye Centre

Reason for visit*

Previous eye problems

Previous eye surgery

Current eye medications

Family eye history

Systemic diseases (tick all that apply)

Diabetes
High blood pressure
Heart failure
Asthma
Arthritis
Cancer
Thyroid disease
COPD
High cholesterol
Hearing loss
HIV
Tuberculosis
Other

Current medications:

Allergies:

Are you a:

Do you drink alcohol

Do you use any of the following medications?

Warfarin
Other blood thinners
Prostate medications
ARV's
Viagra or similar
Homeopathic medications
Plasmaquine
Tamoxifen

VITAL SIGHT