Elgin Eye Clinic
202 Suites 2521 Technology Dr
Elgin, IL 60124
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Patient Forms in Elgin, IL

Medical History Form
Please Answer the Following To The Best of Your Ability:
Do YOU have or are YOU being treated for problems with any of the following:
Please select as many as apply
Select any surgeries/procedures you have had in the past:
Do any of your BLOOD RELATIVES have (or had) any of the following:
How many packs of cigarettes do (OR DID YOU) smoke per day?
How many total years did you smoke?
How many years ago did you quit?
How many alcohol drinks do you have per day?
Marital Status
Employment Status
How old is your current contact lens prescription?
Please click if you have had any of the following symptoms over the past three months:
NOTE: This is a secure form and will not be seen by anyone other than The Elgin Eye Clinic.