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
Year
Year
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
Year
Year
OCULAR (EYE) SURGERY (Please list all eye surgical procedures and when) NONE
Year
Year
Year
FAMILY HISTORY (Please circle all that apply and indicate relation) NONE
Relation
Relation
Relation
Cataracts
Blindness
Migraine
Diabetes
Cancer
Retinal Detachment
Glaucoma
CVA
Strabismus
AMD
Heart Disease
SOCIAL HISTORY (Please check all that apply)
CIGARETTE SMOKING:
ALCOHOL USE:
ILLICIT DRUG USE:
SAFETY:
PEDIATRIC HISTORY (Complete only if patient is a child)
Gestational Age at Birth:     weeks
Birth Weight: lbs     oz
Maternal Illness during pregnancy
REVIEW OF SYSTEMS (Please check all that apply)
EYES / VISION
ENDOCRINE
CONSTITUTION / SYSTEM
ENT AND MOUTH
CARDIOVASCULAR
RESPIRATORY
GASTROINTESTINAL G.I.
MUSCULOSKELETAL
INTEGUMENTARY
NEUROLOGICAL
PSYCHIATRIC
HEMATOLOGIC / LYMPHATIC
ALLERGIC / IMMUNOLOGIC
PLEASE COMPLETE BOTH PAGES OF THIS FORM. THANK YOU