Medical History form

Optometry and Ophthalmology Patient Medical History Form

Summit Eye Care
Full Name*
Exam Date*

MonthDayYear
Date
Personal Ocular History
Last eye exam date?*

MonthDayYear
Date
Do you wear glasses?*

YesNo
If yes, how old are they?
Do you wear contact lenses?*

YesNo
If yes, what brand are they?
How old is your current pair?
How many years have you worn contact lenses?
Do you have any of the following vision concerns?*

Blurry VisionEyestrainSevere Sensitivity to LightFrontal HeadachePoor Night VisionGlareDouble VisionDistorted VisionFluctuating Vision
Please list any additional vision concerns
Do you have any of the following eye health concerns?

RednessBurningItchingTearing/WateringDischargeDrynessEye PainEye SorenessFlashes and/or Floaters
Please list any additional eye health concerns
Have you ever been diagnosed with any of the following ocular conditions?

CataractsGlaucomaMacular DegenerationDiabetic RetinopathyKeratoconusLazy EyeDry EyeEye Infection/InflammationContact Lens OverwearRetinal ConditionEye Trauma/Injury
Please list any additional diagnosed ocular conditions
Have you ever had any ocular surgeries?*

YesNo
If yes, please list
Social History
Occupation*
Hobbies*
Approximately how many hours do you spend on a computer daily?*
Review of Systems

Please mark beside any condition you currently have.
Constitutional

Developmental DisabilitiesCancerUnintentional Weight LossPregnant
ENT

Hearing LossSInusitisDry MouthLaryngitis
Neurological

Multiple SclerosisEpilepsyCerebral PalsyTumorStroke/CVAMigraine
Psychological

DepressionAttention DeficitAnxiety OrderBipolar Disorder
Cardiovascular

HypertensionStroke/CVAHeart DiseaseVascular DiseaseCongestive Heart Failure
Respiratory

AsthmaBronchitisEmphysemaChronic ObstructionSleep Apnea
Gastrointestinal

Chron'sColitisUlcerAcid RefluxCeliac Disease
Genitourinary

Kidney DiseaseProstate Disease/Cancer
Musculoskeletal

ArthritisOsteoarthritisFibromyalgiaMuscular DystrophyAnkylosing SpondylitisOsteoporosisGout
Dermatological

EczemaRosaceaPsoriasisHerpes Simplex/Cold SoresHerpes Zoster/Shingles
Endocrine

Type 2 Diabetes MellitusType 1 Diabetes MellitusThyroid DysfunctionHormonal Dysfunction
Hematological/Lymphatic

AnemiaLarge-Volume Blood LossUlcerHigh Cholesterol
Allergic/Immune

Environmental AllergiesRheumatiod ArthritisLupusSjogren's Syndrome
Current Prescription and Non-Prescription Medications (including Eye Drops):*
Allergies to medication*
Family History

Please list parents, grandparents, siblings, or children - living or deceased - with the following conditions:
Glaucoma*
Diabetes*
Lazy Eye*
Heart Disease*
Macular Degeneration*
High Blood Pressure*
Color Blindness*
Kidney Disease*
Retinal Detachment*
Lupus*
Keratoconus*
Thyroid Disease*
Patient Signature*

Clear
Should be Empty:

Optometry and Ophthalmology Patient Medical History Form

Personal Ocular History

Social History

Review of Systems

Family History