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South Lyon: 248-437-3351

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Patient History Form

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • What are your visual symptoms today:

  • Blurred Vision/Distance
  • Blurred Vision/Near
  • Double Vision
  • Eye Strain
  • Eye Infections
  • Eye Pain/Soreness
  • Tired Eyes
  • Burning Eyes
  • Itchy Eyes
  • Dry Eyes
  • Red Eyes
  • Watery Eyes
  • Wandering Eye
  • Mucus Discharge
  • Floaters or Spots
  • See Flashes
  • See Halos
  • Poor Night Vision
  • Headaches
  • Migraine Headaches
  • Loss of Vision
  • Crossed Eyes
  • Light Sensitive
  • Gritty Feeling
  • Poor Color Vision
  • Droopy Lid
  • PERSONAL MEDICAL HISTORY (REVIEW OF SYSTEMS)

    PLEASE CHECK ANY OF THE FOLLOWING THAT APPLIES TO YOU. IF YOU HAVE NONE OF THESE CONDITIONS, PLEASE CHECK NONE.
  • Past Medical History

  • Have you ever been diagnosed with?
  • Family History

    Has anyone in your family (grandparents, parents, siblings, children, living or deceased) been diagnosed with:

Voted Best Eyecare in West Oakland County

We are back and seeing ALL patients!  We want to assure you that we take the health and well-being of our patients, staff, and community seriously.  We are taking all necessary precautions, as advised by the CDC, to prevent the spread of COVID-19.

Here are some ways we will promote the safety of our patients and staff:

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