Medical History
VISUAL HISTORY:
Briefly describe the main reason for having an examination today:
Associated: Do you have any other symptoms related to this?
Other eye issues or problems
I currently wear glasses:
Part-time
Full-time
If part-time, how often/when?
I currently wear contacts:
Part-time
Full-time
If part-time, how often/when?
Contact lens wearers: Are your lenses comfortable?
Yes
No
Rigid Gas Permeable
Soft
What solution do you use?
Current Brand:
What is your replacement schedule?
How old is your current pair?
Please list all eyedrops you use (OTC and Rx):
How often used?
List any eye surgeries:
Other eye disease or condition:
Describe any eye injuries:
How many hours a day do you use a computer?
Describe any visual symptoms from computer use:
______________________________________________________________________________________________________________________________________________________
MEDICAL HISTORY / REVIEW OF SYSTEMS:
Physician's Name:
Last Visit Date:
List all medications you are currently taking (including any OTC/vitamins):
Allergies/Alerts:
Height
Weight
Are you pregnant or nursing?
Yes
No
If yes, what is the due/birth date?
Do you have, or ever had, any CHRONIC problems in the following areas? -
Notes:
______________________________________________________________________________________________________________________________________________________
FAMILY HISTORY
Family history is unknown/adopted
Any history of the following in any family members (parents, grandparents, siblings, children)? -
If yes, what disease?
______________________________________________________________________________________________________________________________________________________
SOCIAL HISTORY (confidential)
How often do you smoke/use tobacco products?
How often do you consume alcohol:
Do you have?
HIV
Hepatitis
STDs
Occupation:
Employer:
______________________________________________________________________________________________________________________________________________________
Who referred you to our office?
If "other", please specify