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
2 digit month, 2 digit day, 4 digit yearDate
Date of Last Eye Exam:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Last Eye Doctor Name & Clinic:
Referred by:
Reason for today's visit:
Eye Health History:
I have a personal history of:
Other Eye Problems:

The following family member has a history of:

The following family member has a history of:

Rows	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):
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:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: