Annual Health & Vision Health History

Annual Health & Vision Health History

A Chance To Grow Vision Clinic
Demographics
Name:*

First NameMiddle InitialLast Name
Date of Birth:*

MonthDayYear
Date
Assigned Gender:*

MaleFemaleOther
Gender if different than assigned:
Pronouns:
Nickname / Preferred Name:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number:*
Please enter a valid phone number.
Email Address:*
example@example.com
How do you prefer to be contacted?*

Home PhoneCell (Call)Cell (Text)Email
Primary language spoken at home:*
Race / Ethnicity:
Do you need an interpreter?

YesNo
Do you want to share emergency contact information?

YesNo
Emergency Contact Name:

First NameLast Name
Relation:
Emergency Contact Phone Number:
Please enter a valid phone number.
Emergency Contact Email Address:
example@example.com
Is the patient a minor? If so, please list the names of the parent/guardian(s):

YesNo
Name of Parent/Guardian (1):

First NameLast Name
Phone Number (1):
If different from above
Name of Parent/Guardian (2):

First NameLast Name
Phone Number (2):
If different from above
Review of Symptoms

Do you have a health condition in any of the following areas? (Specify)*

	Please Explain
Constitution / Neuro / Psych
ENT / Respiratory / Pulmonary
Cardiovascular
High Blood Pressure / Diabetes
Immune / Allergy
Vision / Ocular

Medications and Supplements (list name and dosage if known):
Does the patient have allergies to medications, food or environment?*

YesNo known allergies
If yes, please specify:
Social History
Tobacco Use?

YesNo
Frequency:
Alcohol Use?

YesNo
Frequency:
Hours of Screen Time? (per day)
Health History

Do you or an immediate family member (Mom/Dad, Sibling, or Child) have currently, or in the past, any of the following health conditions?

Eye Condition:

	Personal	Family (list relation)
Cataract
Glaucoma
Macular Degeneration
Retinal Detachment
Strabismus / Amblyopia (Eye Turn or Lazy Eye)
Other (specify)

Is the patient adopted and the family history unknown?

YesNo
Reason for today's visit:*

Annual ExamOther
If "Other," please explain:
Last eye exam and clinic (if known):
Do you currently wear eyeglasses or contact lenses?*

YesNo
Have you ever worn eyeglasses or contact lenses in the past?*

YesNo
Do you have any interest in a contact lens fitting?*

YesNo
Do you have dry eye concerns?

YesNo
If yes, please complete the SPEED Questionnaire.
Do you have functional vision concerns (Reading, Double Vision, Eye Turn, Post-Concussion)?

YesNo
If yes, please complete the Quality of Life Checklist.
Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty: