Patient HEALTH History

Patient HEALTH History

Dr. Gerald Matsuda Dr. Stuart Machida Dr. Kari Chang-Moses Dr. Shelley Tasaka Dr. Jenny Nguyen
Name
Reason for Visit:

Other
How Long Ago Was Your Last Complete Eye Exam?
Dilated
Who Was Your Last Eye Doctor?
Who Is Your Primary Care Physician?
Do you Wear Glasses
How Old Are Your Present Glasses?
Have You Ever Worn Contact Lenses?
Do You Currently Wear Contact Lenses?

Other
State Contact Lens Type
Please include Brand, Base Curve (B.C.), Diameter (Diam.), Power
If No, Are You Interested In Wearing Contact Lenses?
Are You Currently Taking Any Drugs Or Medications?

Other
Are You Currently Allergic To Any Drugs Or Medications?

Other
Have You Ever Had Any Eye Disease, Eye Injury, Or Eye Surgery?

Other
Do You Currently Smoke
Have You Ever Smoked Before?
Do You Drink Alcohol?
Do You Use Recreational Drugs?
Height
Weight

Do You Have Any Of The Following Problems/Conditions (Please List):

Rows	Yes	No	Please List
Allergy (Hay Fever, Atopy, Etc.)
Cardiovascular (High Blood Pressure, Cholesterol, Heat Problems Etc.)
Constitutional (Fever, Weight Loss/Gain, Fatigue, Etc.)
Endocrine (Diabetes, Hormone, Thyroid, Etc.)
Gastrointestinal (Hernia, Ulcers, Acid Reflux, Etc.)
Genitourinary (Bladder Infection, Kidney Stones, Prostate, Etc.)
Head (Ears, Nose, Mouth, Throat) (Hearing Loss, Cough, Congestion, Dry Mouth, Etc.)
Hematologic/Lymphatic (Anemia, Blood Disorder, Bleeding Problems, Etc.)
Integumentary (Skin, Rashes, Acne, Eczema, Etc.)
Musculoskeletal (Arthritis, Joint, Osteoporosis, Etc.)
Neurological (Multiple Sclerosis, Headaches, Migraines, Etc.)
Psychiatric (Anxiety, Depression, ADHD, Bi-Polar, Etc.)
Respiratory (Asthma, Emphysema, Bronchitis, Etc.)
Currently Pregnant/Nursing

Do You Have Any Family History of: (Please List Family Member)

I ACKNOWLEDGE THAT I RECEIVED A COPY OF WINDWARD VISION CENTER’S NOTICE OF PRIVACY PRACTICES.
Signature

Please sign.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number

Area CodePhone Number
46-056 Kamehameha Highway., Kaneohe, HI 96744, Ph. (808) 235-6641

30 Aulike Street, Suite 102, Kailua, HI 96734, (808) 262-8107
Should be Empty: