Medical History NEW

Medical History
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Today's Date*

MonthDayYear
SSN
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Last Eye Exam

MonthDayYear
Location/Doctor
Name of Primary Care Physician
Last Medical Exam
Doctor's Phone

Area CodePhone Number
Name of Pharmacy
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you hear of our office?
Any allergies to medications?*
If yes, explain
List any medications you are taking (Including oral contraceptives, aspirin, OTC meds and home remedies)*
List all major injuries, surgeries and/or hospitalizations you have had*
Select any of the following that you have ever had*

Crossed EyesLazy EyeDrooping EyelidProminent EyesGlaucomaRetinal DiseaseCataractEye InfectionsEye InjuryNone of the above
Are you pregnant and/or nursing?*
Do you wear glasses?*
If yes, how old is your present pair of lenses?
Do you wear contacts?*
If yes, how old is your present pair of lenses?
Type of contact lenses?

RigidSoftExtended WearOther
Are they comfortable?

YesNo
Have you ever had corneal molding technique performed (aka CRT Orthokeratology)?*
Have you ever had lasik or any other corneal refractive surgical procedure performed?*
Family History

Immediate Family Only
Please note any family history (immediate family only - parents, siblings, children, etc.) for the following conditions:
Blindness*
Relationship to you
Cataract*
Relationship to you
Crossed Eyes*
Relationship to you
Glaucoma*
Relationship to you
Macular Degeneration*
Relationship to you
Retinal Detachment/Disease*
Relationship to you
Arthritis*
Relationship to you
Cancer*
Relationship to you
Diabetes*
Relationship to you
Heart Disease*
Relationship to you
High Blood Pressure*
Relationship to you
Kidney Disease*
Relationship to you
Lupus*
Relationship to you
Thyroid Disease*
Relationship to you
Other
Relationship to you
Social History

All information is kept confidential
Do you drive?*

YesNo
If yes, do you have visual difficulty when driving?

YesNo
If yes, please describe
Do you use tobacco products?*

YesNo
If yes, type, amount, and how long?
Do you drink alcohol?*
Do you use illegal drugs?*

YesNo
If yes, describe type, amount, and how long?
Select any of the following that you have ever been exposed to or infected with*

GonorrheaHepatitisHIVSyphilisNone of aforementioned
Review of Systems

Please select any of the following that you have, or have ever had problems with
Constitutional

FeverWeight LossWeight Gain
Neurological Disorder

HeadachesMigrainesSeizures
Eyes

Loss of VisionBlurred VisionDistorted Vision/HalosLoss of Side VisionDouble VisionDrynessMucous DischargeRednessSandy or Gritty FeelingItchingBurningForeign Body SensationExcess Tearing/WateringGlare/Light SensitivityEye Pain or SorenessChronic Infection of Eye or LidStyes or ChalazionFlashes/Floaters in VisionTired Eyes
Endocrine

ThyroidOther Glands
Ears, Nose, Mouth, Throat

Allergies/Hay FeverSinus CongestionRunny NosePost-Nasal DripChronic CoughDry Throat/Mouth
Respiratory

AllergiesAsthmaChronic BronchitisEmphysema
Vascular/Cardiovascular

Diabetes Type 1Diabetes Type 2Gestational DiabetesHeart PainHigh Blood PressureVascular Disease
Gastrointestinal

Acid Reflux
Genitourinary

Genitals/Kidney/Bladder
Bones, Joints, Muscles

Rheumatoid ArthritisMuscle PainJoint Pain
Lymphatic/Hematologic

AnemiaBleeding Problems
Allergic/Immunologic/ Psychiatric

DepressionAnxietyBipolar
If you have a condition that is not listed, please explain and list any medications being used to treat it
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Medical History

Family History

Social History

Review of Systems