PATIENT MEDICAL HISTORY
|Decreased distance vision?
||Decreased near vision?
|Decreased computer vision?
||Night glare or halos?
||Burning or stinging?
|Sensitive to light?
||Tearing or watering?
|Do you see flashes of light?
||Do you see floaters?
Do you have headaches?
If yes, how often?
Please select any problems you may have from the drop downs below.
Please list any Injuries, Surgeries, Hospitalization
Pregnant Or Nursing:
Recent Tetanus Shot:
Primary Care Physician:
Reason For Visit:
List any Vitamins you take:
Please list any over the Counter medications:
Please list your current Prescription Medications:
No Current Medications
Please list all drug allergies:
No Known Drug Allergies
FAMILY MEDICAL HISTORY
Do you have a history of any of the following in your family? (Please select from the drop downs below.)
PATIENT OCULAR HISTORY
Please select if you have had any of the following:
Please select your current Eye Meds:
Last Eye Doctor:
Last Eye Exam:
FAMILY OCULAR HISTORY
Glaucoma: Crossed / Lazy:
Retinal Detach: Macular Degeneration: Cataracts:
Primary Vision Correction: Planning to get new
Back up specs?
Type of CLs worn in past: Wear Time: Cleaner: Disposal:
DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?
|GENERAL: Fever, weight loss, weight gain, fatigue?
|EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
|CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
|RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
|GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
|MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
|SKIN: growths, rashes, acne
|NEUROLOGICAL: Headaches, migraines, seizures
|PSYCHIATRIC: Depression, Anxiety, Insomnia
| ENDOCRINE: Thyroid, Diabetes
|BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
|ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, M.S., Lupus,
|GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux