Patient Health History Template

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VISTA LINDA EYE CARE, INC.
PATIENT HEALTH HISTORY
REV 9.3.11
Patient Name:______________________________________________
DOB_____/_____/_______
Gender:
M
F
Primary Care Physician:
_______________________________
Date Last Seen by PCP:
________________
Medical/Family History
(use back sheet if more space is needed)
Please list all your current medications (include over the counter, vitamins and herbal therapy):__________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
List all major surgeries (Eye Surgery included):_________________________________________________________________________
_______________________________________________________________________________________________________________
List allergic conditions:(e.g. medications, seasonal, mold, dust, latex, eye drops):____________________________________________
_______________________________________________________________________________________________________________
Please indicate if any of the conditions apply to you or a family member
(blood relatives only).
Disease/Condition
Yourself
Yes
No
Yes
No
Cataract
□
□
Women are you Pregnant?
□
□
Eye Turn
□
□
Are you breast feeding?
□
□
Glaucoma
□
□
Macular Degeneration
□
□
Retinal Detachment
□
□
Family Member
Indicate Relationship
(Blood Relatives Only)
Yes
No
(M - Mother F - Father G – Grandparent A - Aunt/Uncle)
Blindness
□
□
_______________________________
Eye Turn
□
□
_____________________________
Glaucoma
□
□
_____________________________
Macular Degeneration
□
□
_______________________________
Retinal Detachment
□
□
_______________________________
Other:_______________________________
_____________________________
Review of Systems
Please indicate below if you have or ever had problems with the following conditions:
Allergic/Immunologic
Ear, Nose and Throat
Gastrointestinal
Skin
Psychiatric
□
□
□
□
□
None
None
None
None
None
□
□
□
□
□
Lupus (SLE)
Sinusitis
Crohn’s Disease
Eczema
Depression
□
□
□
□
□
Rheumatoid Arthritis
Upper Respiratory
Colitis
Rosacea
Bi-Polar
□
□
□
□
Environmental Allergies
Tract Infection
Acid Reflux/Ulcer
Psoriasis
Schizophrenia
□
□
□
□
□
Other _________________
Other ______________
Other ___________
Other ______________
Other _____
Cardiovascular
Endocrine/Glands
Respiratory
Muscle/Skeletal
Genital/Urinary
□
□
□
□
□
None
None
None
None
None
□
□
□
□
□
High Blood Pressure
Diabetes
Asthma
Arthritis
Urinary Tract Infection
□
□
□
□
□
Heart Disease
Hormone Dysfunction
Bronchitis
Fibromyalgia
HIV Positive
□
□
□
□
□
Stroke
Thyroid Dysfunction
Emphysema
Lupus _____________
Herpes/Chlamydia
□
□
□
□
□
Vascular Disease
Other _____________ _
Other ___________
Other ___________ ___
Other
Hematologic/Lymphatic
Neurological
General Health
Social
□
□
□
□
□
None
None
None
Tobacco Use:
Y
N
□
□
□
Anemia
Multiple Sclerosis
Weight loss/gain
Current Smoker
Previous Smoker
□
□
□
Leukemia
Epilepsy
Fever
Non-Prescription Drugs
Y
N
□
□
□
Bleeding Disorder
Migraines
Fatigue
Alcohol Consumption
Y
N
□
□
□
Other ___________________
Other _______________
Trauma
Weight
Height_
__________________
___________
Please sign below to acknowledge that this form is current:
Signature:__________________________________________ Date:________________________ Reviewed by Doctor’s initials :___________
Acknowledgment
of Receipt of Notice of Privacy Practices
My signature below verifies that I have received a copy of the Vista Linda Eye Care, Inc. Notice of Privacy Practices.
Name of Patient (Print)__________________________________________ Signature of Patient:________________________________Date:___________
Signature of Patient Representative (if patient is a minor or an adult unable to sign this form) _________________________________________________
Relationship of Patient Representative to Patient ____________________________________________________________________

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