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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.
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In response to the recent announcement of Governor Abbott’s Executive Order on the mask mandates, we would like to reinforce the importance of mask-wearing in our office as recommended by the CDC and the State and Federal Optometric organizations. All staff members, patients and guests will be required to wear a mask in our office even if vaccinated. Although we have been encouraged by the recent declining COVID-19 cases and hospitalizations as well as increasing vaccinations, it is essential to continue our safety efforts to help stop the spread and reduce transmission as new COVID-19 variants spread across our communities.

Our top priority is the safety of our team members, patients and their families. Thus, we will continue to enforce all of our existing COVID-19 prevention protocols by diligently disinfecting all surfaces, practicing hand hygiene, socially distancing and wearing a mask in the office. We truly appreciate your support and understanding as we protect our employees, patients and communities.

Baker Family Eyecare Management