Patient Medical History Form

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PATIENT MEDICAL HISTORY FORM
Personal Information
Date ______________
Mr. Mrs. Ms. Dr. Rev.__________________________________________ Gender: (Please circle) M F
Street Address: ___________________________ City______________ State_________ Zip __________
Phone Home#_________________________ Work # ______________ Cell/Alt# ___________________
Email Address _________________________
Date of Birth _____________ Social Security # ____________________ Occupation _________________
Name of Parent/ Spouse _________________ Hobbies/Sports __________________________________
I have been provided with a copy of the HIPPA privacy policy to read. Signature ____________________
I authorize the following people to pick up prescriptions and records on my behalf __________________
Medical and Ocular History
Do you wear contact lenses? Y/N Brand: ___________ Are you interested in contact lenses? Y/N
Do you wear glasses? Y/N
When was your last eye exam? Date _______________ Where was it? ___________________________
Who was your Doctor? __________________________
Do you work at a computer terminal?
Y/N
How many hours per day? __________________
Are you interested in refractive surgery? Y/N
Do you or any family member have a history of the following:
Eye Related
No
Yes
Eyes Continued:
No
Yes
Self/ Family
Self/
Family
Blindness
Glaucoma
Blurred vision
Halos
Burning/itching
Loss of vision
Cataracts
Macular Degeneration
Chronic eye Infections
Mucous discharge
Crossed eyes
Red eyes
Double vision
Retinal detachment
Dry eyes
Retinal problems
Excessive tearing
Other
Eye allergies
Cancer
Eye pain/soreness
Diabetes
Eye surgery
Headaches
Flashes/floaters
Heart Disease
Glare/light sensitivity
High Blood Pressure
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