Medical History
After Completing All Forms Submit Final Data on
Submit Data Tab
MEDICAL HISTORY
Date of Last Medical
Exam:
Name of Medical Doctor:
Doctor's Phone #:
What is you general health status?
List all medications you are taking:
Do you have allergies to medications?
If yes, to what?
What happens?
Do you have general allergies?
If yes, to what:
What happens?
List all major illnesses, injuries, surgeries and/or
hospitalizations you have had:
Ladies:
Are you pregnant? Are you nursing?
_________________________________________________________________________________________________________________________________________________________________________________________________________________________
ADDITIONAL INFORMATION Please fill out the fields
below:
Preferred Language:
Race:
Ethnicity:
Height Feet: Inches:
Weight (lbs):
________________________________________________________________________________________________________________________________________
OCULAR HISTORY
Date of Last Eye Exam?
Do you wear eyeglasses?
Do you wear
contact lenses?
If yes, what type?
If yes,
what solution/care system?
List any current eye drops:
List any current or past eye diseases, eye injuries or
eye surgeries:
List
any family members that are patients in our office:
________________________________________________________________________________________________________________________________________
* If adopted select yes and move to the Social
History section
________________________________________________________________________________________________________________________________________
FAMILY HISTORY
Please note any family
history (parents, grandparents, siblings, children, living or deceased) for the
following conditions:
Disease/Condition Y/N Relationship To You
Blindness
Cataract
Crossed Eyes
Glaucoma
Macular Degeneration
Retinal Detachment/Disease
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Stroke
Kidney
Disease
Lupus
Thyroid Disease
Other
________________________________________________________________________________________________________________________________________
SOCIAL HISTORY
This information is a protected part of you medical record and is kept strictly
confidential. However, you may discuss this portion directly with the doctor if
you prefer.
Does your vision limit activities of daily living? (driving, reading,
working, etc.)
If yes, please describe:
Do you use tobacco products? If yes, type/amount/how long?
Do you drink alcohol? If yes, type/amount/how long?
Do you do illegal drugs? If yes, type/amount/how long?
Have you ever been exposed to or infected with?
HIV Hepatitis Tuberculosis Syphilis Gonorrhea Chlamydia
_______________________________________________________________________________________________________________________________________
REVIEW OF SYSTEMS
Do you currently, or have you ever had
any problems in the following areas:
CONSTITUTIONAL
If
yes, please explain or describe:
Fever, Weight Loss/Gain
INTEGUMENTARY
Skin
NEUROLOGICAL
Headaches
Migraines
Seizures
EYES
Loss of Vision
Blurred Vision
Distorted Vision/Halos
Loss of Side Vision
Double Vision
Dryness
Mucous Discharge
Redness
Sandy or Gritty Feeling
Itching
Burning
Foreign Body Sensation
Excess Tearing/Watering
Glare/Light Sensitivity
Eye Pain or Soreness
Chronic Eye or Lid Infection
Sties or Chalazion
Flashes/Floaters in Vision
Tired Eyes
ENDOCRINE
Thyroid/Other Glands
EAR, NOSE, MOUTH, THROAT
Allergies/Hay Fever
Sinus Congestion
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Throat/Mouth
RESPIRATORY
Asthma
Chronic Bronchitis
Emphysema
VASCULAR/CARDIOVASCULAR
Diabetes
Heart Disease
High Blood Pressure
High Cholesterol
Vascular Disease
GASTROINTESTINAL
Diarrhea
Constipation
GENITOURINARY
Genital/Kidney/Bladder
BONES/JOINTS/MUSCLES
Arthritis
Muscle Pain
Joint Pain
LYMPHATIC/HEMATOLOGIC
Bleeding Problems
Anemia
ALLERGIC/IMMUNOLOGIC
PSYCHIATRIC
If you have a condition not listed please explain or describe it:
________________________________________________________________________________________________________________________________________