Medical History Form

Medical History
Full Name*

First NameLast Name
Date

MonthDayYear
Date
What brings you in today?
Please list all eye health problems/symptoms*:
Medical insurance will only contribute to the cost of the exam if there is a medical reason for the exam, such as loss of vision, headaches, eye redness, eye pain, eye itching, glaucoma, cataracts, floaters, dry eyes, etc.
Which eye has the problem?
Does the problem cause vision loss or blur?
Did the problem occur suddenly or gradual?
How severe is the problem?
Is it worse at any specific distance?
How long does the problem last?
How long has the problem been occurring?
Are there any associated symptoms?

NoHeadachePainLight sensitivityOther
Does anything help with the problem?
Have you had any major illnesses, injuries, or operations?
Please describe
Please list any medications you are currently taking:
Include over the counter and prescription medications.
Date of Last Medical Exam:
Doctor:
For women: Are you pregnant or nursing?

NoPregnantNursing

Family Health History: Please select any condition in your family history and indicate the relative affected:

	Father	Mother	Maternal Grandfather	Maternal Grandmother	Paternal Grandfather	Paternal Grandmother	Sibling
Glaucoma
Corneal Problem
Diabetes
Macular Degeneration
Crossed Eyes
Heart Disease
Retinal Problem
Lazy Eye
High Blood Pressure

Your Occupation/Grade:
Place of Employment/School:
Please list your hobbies, sports, and visual needs:
How many hours do you use a computer each day?
Have you been exposed to any of the following conditions?

HerpesHIVTBHepatitisOther
Do you use or do you have history of using tobacco?*
Do you use or do you have history of using illegal drugs?*
How often do you consume alcohol?*

DailyWeeklyMonthlyOccasionallyNever
Please list the names and ages of all members of your household:
Please select any of the following eye problems you have experienced:

Loss of visionBlurred visionDouble visionCataractsCrossed eyesFlashesFloatersDry eyesWatery eyesRed eyesMucous dischargeBurning or itchingSandy or gritty feelingEye pain or sorenessLight sensitivityChronic eye infectionsTired eyes/eyestrainHalos/GlarePrevious vision therapyPrevious eye surgeryPrevious eye injuryRetinal detachmentGlaucomaOther
Please select any of the following health conditions you have experienced:

Hay fever/allergiesMedicine allergiesLupusSjogrensFeverRecent weight lossHeart disorderHigh blood pressureVascular diseaseSinus problemsDry throat/mouthChronic ear infectionsDiabetesThyroid problemsOther gland issuesGenitalsKidney/bladder issuesAnemiaHigh cholesterolSkin issuesBreast issuesArthritisRheumatoid arthritisMuscle pain/joint painHeadachesMigrainesSeizuresMultiple SclerosisNervous disordersDepressionAsthmaShortness of breathEmphysemaLung cancerOther
If you answered "yes" to eye injury or eye surgery, please describe:
If you answered "yes" to high blood pressure, what was your last blood pressure measurement?
If you answered "yes" to diabetes, when were you diagnosed?
Please list your last blood sugar:
Please list your last Hemoglobin A1C:
I attest that the above information is accurate to the best of my knowledge:

Clear
Should be Empty: