Medical History Form Save time at your first appointment Fill out our new patient form before your next visit to Levin Eyecare Step 1 of 4 25% General InformationLast Exam*How long ago was you last exam?1 Month Ago2 Months ago3 Months ago6 Months ago9 Months ago1 Year ago1¼mYears ago1½ Years ago1¾ Years ago2 Years ago2¼ Years ago2½ Years ago2¾ Years ago3 Years ago3¼ Years ago3½ Years ago3¾ Years ago4 Years ago4¼ Years ago4½ Years ago4¾ Years ago5 Years ago5¼ Years ago5½ Years ago5¾ Years agoToo Long agoDon't KnowExam Type Wanted*Select a ServiceCheck UpFor GlassesFor Contact LensesFor Glasses & ContactsLASIK ConsultationMedical ConsultationExam Follow UpContact Follow UpSurgical Follow UpNot SureSelect Office*Select a LocationBel AirBelvedere SquareEldersburgLuthervilleOverleaParkvillePerry HallPikesvilleReisterstownTowsonWestminsterSelect Doctor*Select a DoctorRichard K. LevinHoward H. LevinIsmail Shalaby, M.D., P.h.D.Michael SandlerChristina AntonopoulosTania MarcicGregory M. BarbushJenna SembratJillian ChapmanSamantha R. HouseJennifer L. StoneRon SurdinBenjamin RubinCarl WaxmanMindabeth LevinDr. Judy HuSendto Email Patient Status*Patient StatusNew PatientCurrent PatientNot a PatientFirst Name*Last Name*Birth Date* GenderSelect GenderMaleFemaleMarital Status*Select StatusSingleMarriedDivorcedWidowedAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Email* Tel*CellLast Four of SSN* Do you currently wear:Glasses?*YesNoSelect TypeDistanceNearBothMonoVisionContact Lenses?*YesNoSelect TypeSoftRigidBothCRTLow Vision Aids?*YesNoDo you currently have or have you ever had any of the following:Had the following? Eye Surgeries Eye Injuries Eye Infections Amblyopia Cataracts Dry Eyes Light Sensitivity Pain Glaucoma Lazy Eye Macular Degeneration Eye Turn In / Out Reading Problems Tracking Problems Other Do you Have:Diabetes*YesNoSelect # of Yearsless than 11 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years11 Years12 Years13 Years14 Years15 Years16 Years17 Years18 Years19 Years20 Years21 Years22 Years23 Years24 Years25 Yearsmore than 25High Blood Pressure*YesNoSelect # of Yearsless than 11 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years11 Years12 Years13 Years14 Years15 Years16 Years17 Years18 Years19 Years20 Years21 Years22 Years23 Years24 Years25 Yearsmore than 25Headaches*YesNoSelect when or how oftenWhen I do close workIntermittentWhen I day driveWhen I night driveDriving day or nightIn the morningIn the afternoonAt the end of the dayless than once a dayOnce a dayTwice a dayMore than twice a dayAll the timeCan't rememberMedicationAre you currently taking prescription or non-prescription drugs?*YesNoAllergiesDo you currently have any allergies known or perceived?*YesNo Do you have problems with any of these systems?Please check all that apply Allergic / Immunologic Arthritis Blood / Lymph Cardiovascular Heart Disease Ear / Nose / Throat Endocrine Glands Gastrointestinal Integument Skin Kidney Problems Musculature Nervous Psychiatric Respiratory Skeletal Bones Thyroid Problems Other (explain bottom of page) Do you useCigarettes?*YesNoPacks per Day½ Pack a Day1 Pack a Day1½ Packs a Day2 Packs a Day2½ Packs a Day3 Packs a DayMore than 3Alcohol?*YesNoFrequencySocial DrinkerOccasionally1 Drink a Day2 Drinks a Day3 Drinks a Day4 Drinks a Day5 Drinks a DayMore than 51 Drink a Week2 Drinks a Week3 Drinks a Week4 Drinks a Week5 Drinks a WeekMore than 51 Drink a Month2 Drinks a Month3 Drinks a Month4 Drinks a Month5 Drinks a MonthMore than 5Other substances?*YesNoSubstancesPrescribed substancesUn-prescribed substanceFamily Eye HistoryAnyone in patient's family (blood relative) had any of the following? Cataracts Cornea Disease Diabetes Glaucoma Lazy Eye Macular Degeneration Retina Disease High Blood Pressure Other Eye Disorders Your Surgical HistoryList any type of surgery and dates of surgery Vision Correction Preferences, InterestsPut a check in any box that interests youLASER VISION CORRECTION Laser vision correction LASIK for Bifocal Vision CONTACT LENSES Contacts that are comfortable ALL day long Disposable contact lenses CRT (Corneal Refractive Therapy) a non-surgical alternative to LASIK Contact lenses to replace glasses Contact lenses that I can sleep in, wake up, and see. (a non-surgical alternative to LASIK) Contact lenses that require no care, to be worn for specific occasions Contact lenses that correct astigmatism Contact lenses that change eye color. (Even without prescription) Bifocal contact lenses No charges for one year for CL Solutions, replacement or power changes, & one office visit EYEGLASSES Extra thin and light eyeglass lenses Crizal anti-reflective (Glare-Free) lenses. Reduce eyestrain. Great for night vision & computers Designer frames - Armani, Calvin Klein, Marchon, Etc. Frames that weigh less than a feather - Airlocks, Silhouette, Etc. Invisible bifocal (No-Line progressives) - Varilux, Seiko, Zeiss, Sola, Etc. Lenses that auto-adjust to comfortable shades of color, based on the light (In/Out door) Cosmetic tinted lenses - also tones down harsh indoor light for those who are light sensitive Specialty Glasses - Sports Frames, Snorkel/Scuba masks, swim, ski Motorcycle, Etc. Discount for second pair CHILDREN'S VISION I need to know at what age should children have their first eye exam I need to know at what age can children wear contact lenses Protective eyeglasses for sports I need to know the difference between Screenings & eye examinations Other InformationPlease elaborate on any information or from any "Other" box above.