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Health History for Integrative Eye Care Consult

Integrative Health History

Please complete this form and process the consultation fee payment in the next page in order to request your integrative health consult with Dr. Lauretta. You will not be able to schedule this visit until this form is submitted and payment is processed.

"*" indicates required fields

Name*

First Last

Do we already have your address on file?

Yes

No

Other

Address*

Street Address City State ZIP Code

Phone Number*

Email Address*

Do we have your Date of Birth on file?

Yes

No

Other

Date of Birth*

MM slash DD slash YYYY

In your own words, what is the main reason you're requesting this integrative health consult with Dr. Lauretta?*

Your Eyes History

Please select the top 1-3 most discomforting symptoms below.*

Please select up to 3 options.

Dry Eyes

Tired Eyes

Itchy Eyes

Red Eyes

Watery Eyes

Pain or discomfort in the eyes

Fluctuating Vision

Blurry vision in one or both eyes

Report the frequency of your symptoms using the rating below.*

Never

Rarely

Sometimes

Often

Always (Constant)

Report the severity of your symptoms using the rating below.*

Not bothersome

Tolerable (Not uncomfortable, very mild)

Uncomfortable (irritating, but does not interfere with my day)

Bothersome (Irritating and interfere with my day)

Intolerable (Unable to perform my daily tasks)

Please list ALL prescribed or over the counter eyedrops that you are currently taking.*

To add more medications, vitamins or supplements, click on the plus sign on the right of the field.

Name of Eyedrop

Dosage and Frequency

Condition being treated

Please list all eye surgeries or procedures below.*

To add more procedures, click on the plus sign on the right of the field.

Type of procedure

Date of Procedure

Which Eye (Left, Right or Both)

Did you have a good outcome?

Your Systemic Health History

When was your last physical?*

Less than 1 year

Between 1-3 years ago.

Over 3 years ago.

Other

When was your last blood work?*

Less than 1 year

Between 1-3 years ago.

Over 3 years ago.

Other

Please list ALL the medications, vitamins and supplements that you are currently taking.*

To add more medications, vitamins or supplements, click on the plus sign on the right of the field.

Name of Medication or Vitamin

Dosage and Frequency

Condition being treated

Current Weight in Lbs*

Current Height in inches*

On average, how many hours of sleep do you get per night?*

How would you describe the quality of your sleep?*

Excellent

Good enough

Poor

What is your energy level on most days?*

Very High

High

Medium

Low

Very Low

Do you experience any pain, stiffness, or swelling on a regular basis? If so, please explain:*

Do you have any of the following Metabolic Health concerns?*

Please select all that apply.

Other, please specify.*

Do you have any of the following Digestive Health concerns?*

Please select all that apply.

Other, please specify.*

What does a typical day of eating look like for you? List a few foods/meals and drinks you usually consume in the corresponding categories:*

Breakfast

Lunch

Dinner

Snacks

Please list any exercise routine below.*

Type of exercise

Frequency

Level of Intensity

Level of enjoyment

Consent*

I agree to the following

I consent that the Company can provide their services and communicate with me via mobile phone, messages, e-mail, and any kind of online communications, provided that these communications comply with privacy regulations.

Appointment Reminders, Reschedules, and Cancellations

I understand that Company can reach me any time to remind me of my appointments or let me know in case of any change about my appointments. And I also understand that the Company can employ and use a third-party automated system to reach out to me for the purpose of "confirm", "reschedule" or "cancel".

Telemedicine Appointments

For telemedicine, I understand the appointments will be held via electronic environments.

Contact Information Change

I accept that I am responsible for notifying the Company when my contact information change.

This service is only for informational purposes and should not be used in place of an actual physician's visit. The information provided is to be used by at your own risk.

Consent Cancellations

I know that I can revoke this consent at any time by contacting the Company.

I consent to the use of mobile phone communications.

I consent to the use of texting (messages) communications.

I consent to receive electronic notifications for confirming, rescheduling, or canceling my appointments.

I sign this consent form on the behalf of

Myself/My family/Someone as a legal guardian

Δ

WELCOME TO MILLENNIUM EYE CENTER

Since 2006, we’ve been the Home for Eye Exams in MetroWest, Orlando, Florida.

At Millennium Eye Center, we offer Eye Exams, Contact Lens Exams, Eyeglasses, and Contact Lenses and all caring vision solutions to enhance lives and keep you seeing 20/20 for life.

Call 407-292-9812 to schedule your appointment and make us your home for eye exams today!

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Monday: 10:00am – 5:00pm

Tuesday: 10:00am – 5:00pm

Wednesday: 12:00pm – 5:00pm

Thursday: 10:00am – 5:00pm

Friday: 10:00am – 2:00pm

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info@drlaurettajustin.com

407-292-9813

6601 Old Winter Garden Rd #104 Orlando, FL 32835

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