Vision Health History

Vision Health History

The following information will assist the doctor with the examination. Please complete all of the questions regarding the person schedule for today's examination.
Client Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Date of Last Eye Exam:

MonthDayYear
Date
Last Eye Doctor Name & Clinic:
Referred by:
Reason for today's visit:*
Eye Health History:

Adopted (family history is not known)
I have a personal history of:

CataractsGlaucoma"Lazy" Eye (Amblyopia)Retinal DetachmentMacular DegenerationOther Eye Problems (specify)
Other Eye Problems:

The following family member has a history of:

Medical Health History
I have a personal history of:

DiabetesHigh Blood PressureHeart ProblemsThyroidSeasonal AllergiesOther Medical Diagnoses (specify)
Other Medical Diagnoses:

The following family member has a history of:

	Present in Family History	Family Member (Relation)	Details
Diabetes
High Blood Pressure
Heart Problems
Thyroid
Seasonal Allergies
Other Medical Diagnoses (specify)

Vision Questionnaire (check all that apply):

Problems seeing in the distanceEyes burnProblems while readingEyes itchProblems seeing doing near activitiesDouble visionWears glassesBlurry visionDifficulty adjusting to current glassesEye rubbingWears contact lensesEye painInterest in wearing contact lensesCurrently pregnantEye surgeryAttempting pregnancy
Eye surgery details:
Additional Information:
Approximately how many hours of screen work does the patient have daily?*
I give permission for any A Chance To Grow, Inc. clinic that may now or in the future be involved with this patient, to share information as well as this health history with the involved clinics.
Client or Guardian Signature:*

Clear
Date:*

MonthDayYear
Date
Should be Empty: