Patient History Form Page 2
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Patient Name:
Acct#:
Please list all individuals you authorize to receive information about your care:
Individual
Relationship
Phone
Current Prescribed/Over-The-Counter Medications:
Name of Prescription/Medication
Taken for what condition
Dosage
Frequency
Have you ever taken any of the following medications? If Yes, please check box
Cardura
Finasteride
Hytrin
Uroxatral
Flomax
Proscar
Past Medical History:List any major illnesses,injuries/surgeries(high blood pressure,heart attack,blood disorders) etc.
Procedure
Reason
When?
VISUAL FUNCTION QUESTIONS
Please check Yes or No if you are experiencing any difficulty with the following while wearing your glasses or contacts:
Yes
No
Comments
Reading small print
Reading newspaper or book
Recognizing people when close
Seeing steps, stairs, or curbs
Difficulty driving on bright sunny days
Difficulty driving at night
Reading traffic signs, street signs
Doing fine handiwork
Writing checks, completing forms
Playing games (i.e. bingo, cards)
Taking part in sports (i.e. golf, tennis)
Cooking/Hobbies
Watching TV
Bothered by glare/halos
If yes, please describe
Are you satisfied with your current vision?
Patient’s Signature:
Date:
Physician’s Signature:
Date:
Reviewed/Updated Date:
Interval Changes
Yes
No MD Signature:
CEI CLN-15 (REV 02/17/11)
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Parent category: Medical