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Medical History Form

  • Please complete the information below and submit the form online or, if you prefer, print out the form after full or partial completion and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.
  • Patient Information

  • Please provide a telephone number, with area code, so we can contact you.
  • Please provide your email address.
  • Date Format: MM slash DD slash YYYY
  • Medical History

  • Include Name of Medication, Dosage, Frequency Taken
  • Family History

    Note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions. When listing relationship, if a grandparent, please specify maternal or paternal.
  • Social History

    This information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer. Please check the box below of you prefer to discuss with the doctor instead.
  • REVIEW OF SYSTEMS

    Do you currently or have you ever had any problems in the following areas?
  • Constitutional

  • Neurological

  • Eyes

  • Endocrine

  • Ears, Nose, Mouth, Throat

  • Respiratory

  • Vascular/Cardiovascular

  • Gastrointestinal

  • Genitourinary

  • Bones/Joints/Muscles

  • Lymphatic/Hematologic

  • Allergic/Immunologic

  • Psychiatric

  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.

To Our Beloved Patients...

We are closely monitoring the fluid situation and want to be extremely vigilant to do our best to flatten out the curve for our community, country and globally. To respect social distancing as recommended by the CDC, the City of Keller, and our various Medical and Optometric Associations, it is with great considerations we must implement some changes to our schedule starting June 1st, 2020. Thank you all for your patience and understanding during this challenging time as we navigate through a global crisis.

Our hours of operation will be 9am-5pm Monday through Friday, closing for lunch from 12:30-1:30. We will be open the 2nd and 4th Saturdays from 9am-2pm.

The front door will be locked, and only scheduled patients will be allowed in the office one at a time. If you arrive at our office, please call 817-562-2020 and let us know the nature of your visit. We will do our best to help you.

We will be providing curb side delivery for ALL materials such as glasses and contacts lenses.

We will be conducting temperature checks of anyone entering the office and have them use hand sanitizer at the door.

Questions that will be asked of patients prior to appointment...

1. Have you or anyone in your household been out of the country in the last month or have traveled to any high-risk areas?

2. Have you or anyone in your household been sick or experiencing any flu or cold like symptoms?

3. Are you having any major vision changes, ocular pain or discomfort? If not, then you may be asked to schedule at a later date.

May God bless you and your family,

Baker Family Eyecare