Medical History Form

Thank you for trusting us with your eye health care. We promise to do our best to provide you with the finest care available. If you have any questions, please do not hesitate to call us.

MEDICAL HISTORY FORM

Birthdate

Patient Name

Gender: Male / Female

Today's Date

Primary Care Physician

Current eye problem / symptoms?

None / Routine Eye Exam

Currently wear contacts? Yes / No

Details

Injury Related? If Yes, How did it occur?

PAST MEDICAL HISTORY

(Please circle all that apply or have applied for you) NONE

Anxiety

Arthritis

Artificial Joints

Atrial Fibrillation

Asthma

BPH

Bone Marrow Transplantation

Breast Cancer

Colon Cancer

COPD

Coronary Artery Disease

Depression

Diabetes

End Stage Renal Disease

GERD

Hearing Loss

Hepatitis

Hypertension

HIV / AIDS

High Cholesterol

Hypothyroidism

Leukemia

Lung Cancer

Lymphoma

Pacemaker / Defibrillator Yes / No

Prostate Cancer

Radiation Treatment

Seizures

Stroke

Valve Replacement

Other

PAST SURGICAL HISTORY (Please list all Surgical Procedures / Hospitalizations and Year) NONE

Year

MEDICATIONS

(Please list all current prescriptions & supplements)NONE

ALLERGIES (Please list all Allergies) NONE

PLEASE COMPLETE BOTH PAGES OF THIS FORM. THANK YOU

OCULAR (EYE) HISTORY (Please list eye conditions and when treated) NONE

Year

OCULAR (EYE) SURGERY (Please list all eye surgical procedures and when) NONE

Year

FAMILY HISTORY (Please circle all that apply and indicate relation) NONE

Relation

Cataracts

Blindness

Migraine

Diabetes

Cancer

Retinal Detachment

Glaucoma

CVA

Strabismus

AMD

Heart Disease

PEDIATRIC HISTORY (Complete only if patient is a child)

Gestational Age at Birth: weeks

Birth Weight: lbs oz

Maternal Illness during pregnancy

PLEASE COMPLETE BOTH PAGES OF THIS FORM. THANK YOU