Patient Medical Health History Form
Name
*
First Name
Last Name
Date of Birth
*
FAMILY HISTORY
Do any of the following run in your blood relatives? (Click all that apply)
*
Glaucoma
Macular Degeneration
Diabetes
Crossed Eyes
Other
PATIENT EYE HISTORY
Do any of the following? (Click all that apply)
Glaucoma
Macular Degeneration
Cataracts
History of Eye Injury
Other
Do you wear contact lenses?
*
Please Select
Yes
No
Do you wear glasses?
*
Please Select
Yes
No
Have you ever been seen by a retinal specialists?
Please Select
Yes
No
Have you ever had any eye related surgeries?
Please Select
Yes
No
If you answered yes on the previous question, please list which kind:
MEDICAL HISTORY
Do you have (or have you had) any of the following medical conditions? (click all that apply)
*
High Blood Pressure
Diabetes
Thyroid Disorder
Headaches
Heart Trouble
High Cholesterol
Stroke
Cancer
Kidney/Urinary
Breathing Problems
Pregnant or Nursing
Other
Have you had any surgeries? (list all below)
What medications are you currently on? (list all below)
Do you have any known drug allergies? (list all below)
SOCIAL HISTORY
Do you use tobacco?
*
Please Select
Yes
No
Do you have a health care proxy?
*
Please Select
Yes
No
Patient Signature
*
Date
*
/
Month
/
Day
Year
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