Medical History Form

Patient Information
Salutation:
First Name *
Middle Initial: *
Last Name *
Sex: *
Referral Source
Address *
City *
Zip *
Today's Date * Pick a date
Primary Phone *
Valid Email *
Work Phone
Employer:
Occupation
Date of Birth * Pick a date
Date of Last Eye Exam Pick a date
Date of Last Medical Exam Pick a date
Name of Medical Doctor
Doctors Phone

Medical History

Please note any family history (parents, grandparents, siblings, childen, both living and deceased) for the following conditions:
Do you have any allergies to medications? * No Yes
If yes, please exlpain:
Please list any medications you take (including oral contraceptives,
aspirin, over the counter medications and home remedies)
Please list all major injuries, surgeries and/or hospitalizations you have had:

Please check any of the following conditions that you have had in the past:
Crossed Eyes:
Lazy Eye:
Drooping Eyelid:
Prominent Eyes:
Glaucoma:
Retinal Disease:
Cataracts:
Eye Infection:
Eye Injury:
Are you currently pregnant or nursing? No Yes
Do you wear glasses? No Yes
If yes, how old are your current pair?
Do you wear contact lenses? No Yes
If yes, how old are your current pair of lenses?
What type of contact lenes do you wear?
Are they comfortable? No Yes

Family History

Please check only those that apply regarding any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:
Blindness:
Relationship to you:
Cataracts:
Relationship to you:
Crossed Eyes:
Relationship to you:
Glaucoma:
Relationship to you:
Retinal Detatchment/Disease:
Relationship to you:
Arthritis:
Relationship to you:
Cancer:
Relationship to you:
Diabetes:
Relationship to you:
Heart Disease:
Relationship to you:
High Blood Pressure:
Relationship to you:
Kidney Disease:
Relationship to you:
Lupus:
Relationship to you:
Thyroid Disease:
Relationship to you:
If there are any other conditions not listed above please explain here:

Social History

This information is kept strictly confidential. However, you may discuss the condition directly with the doctor if you prefer.
I would prefer to discuss my social history information directly with my doctor.
Do you drive? No Yes
Do you have difficulty driving? No Yes
If yes, please exlpain:
Do you use tobacco products? No Yes
If yes, what type and how long?
Do you drink alcohol? No Yes
If yes, what type and how long?
Do you use illegal drugs? No Yes
If yes, what type and how long?
Have you ever been exposed to or infected with Gonorrhea, Hepatitis, HIV, or Syphilis? No Yes
If yes, please exlpain

Review of Systems

Please check only those that apply if you currently, or have ever had any problems in the following areas:

Constitutional:
Fever, Weight Loss/Gain: Yes

Integumentary:
Skin Yes

Neurological:
Headaches: Yes
Migraines: Yes
Seizures: Yes

Eyes:
Loss of Vision: Yes
Blurred Vision: Yes
Distorted Vision: Yes
Loss of Side Vision: Yes
Double Vision: Yes
Dryness: Yes
Sandy or Gritty Feeling: Yes
Itching: Yes
Burning: Yes
Foreign Body Sensation: Yes
Excess Tearing or Watering: Yes
Mucous Discharge: Yes
Glare or LIght Sensitivity: Yes
Eye Pain: Yes
Chronic Infection of Eye or Eyelid: Yes
Sites or Chalazion: Yes
Flashes or Floaters in Vision: Yes
Tired Eyes: Yes

Endocrine:
Thyroid or Other Glands: Yes

Ears, Nose, Mouth, Throat:
Allergies or Hay Fever: Yes
Runny Nose: Yes
Sinus Congestion: Yes
Post-Nasal Drip: Yes
Chronic Cough: Yes
Dry Throat or Mouth: Yes

Respiratory:
Asthma: Yes
Chronic Bronchitis: Yes
Emphysema: Yes
Diabetes: Yes
Heart Pain: Yes
High Blood Pressure: Yes
Vascular Disease: Yes

Gastrointestinal:
Diarrhea: Yes
Constipation: Yes

Genitourinary:
Genitals/Kidney/Bladder: Yes

Bones, Joints, Muscles:
Rheumatoid Arthritis: Yes
Muscle Pain: Yes
Joint Pain: Yes

Lymphatic/Hematologic:
Anemia: Yes
Bleeding Problems: Yes

Allergic/Immunologic Problems:

 Yes

Psychiatric Problems:

 Yes
If you selected any of the above or have a condition not listed please explain here:
Verification:
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