Patient History Form
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Today’s Date:
Acct#: ______________________
PATIENT HISTORY FORM
Patient Name:
SS#:
Date of Birth:
Home Phone: ______________________
Work Phone: ______________________ Cell Phone: ____________________
Employer: ____________________________________________
Occupation: __________________________________
Primary Care Physician:
Optometrist:
Cardiologist:
Medication Allergies & Reactions:
Pharmacy: ______________________________ Pharmacy Phone # (
)___________________________________
History of Latex Allergy?
YES
NO
Height:________ Weight: ________ Language: ___________________
Race:
American Indian / Alaskan Native
Asian
African American
Caucasian
Hispanic / Latino
Native Hawaiian or Other Pacific Islander
Other
Ethnicity:
Hispanic
Non-Hispanic
Have you or any family members had an anesthesia reaction?
YES
NO
REVIEW OF SYSTEMS -
Do you currently have any of the following problems?
Date
System
Condition/Current Treatment/Surgery
Yes/No
Diagnosed
Eye disease, eye injury, eye surgery
Yes
No
Constitutional
(fever, weight loss, other)
Yes
No
Ears
(reduced hearing or hearing loss)
Yes
No
Nose/Mouth/Throat
(sinus problems, sore throat)
Yes
No
Cardiovascular
(heart,vascular) hypertension
Yes
No
Pacemaker/Defibrillator
Yes
No
Respiratory
(breathing problems, lungs, cough)
Yes
No
Gastrointestinal
(heartburn, diarrhea, vomiting,
Yes
No
GERD, acid reflux)
Neurological
(numbness, weakness, stroke,
Yes
No
headaches, paralysis,)
Females –
Pregnant? / Nursing?
Yes
No
Genitourinary
(male or female organ problems,
Yes
No
urinary problems, kidneys)
Dialysis
Yes
No
Dermatologic
(skin rashes, excessive dryness)
Yes
No
Musculoskeletal
(muscle or joint problems)
Yes
No
Rheumatoid Arthritis
Yes
No
Diabetes/Thyroid
Yes
No
Allergic/Immunologic
Yes
No
Psychiatric
(depression)
Yes
No
Hematologic
(bleeding tendency, anemia)
Yes
No
Cancer
:
(Type)
Yes
No
FAMILY HISTORY:
SOCIAL HISTORY:
Yes
No
High blood pressure
Marital Status:
Married
Single
Widowed
Yes
No
Diabetes
Currently Employed:
Yes
No
Yes
No
Glaucoma
If yes, occupation:
Yes
No
Cataracts
Use of Tobacco/Alcohol/Drugs:
Yes
No
Yes
No
Retinal disease
Comments:
Yes
No
Other eye problems ________________________________________________________________
CEI CLN-15 (Rev. 09/13/10)
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