Personal Health History
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1
2Today’s Date:__________
MR#__________________
Personal Health History
Patient
Name:___________________________Occupation: ________________DOB:_______Age:______
Please explain your present eye health and vision condition (if known):
YES
NO
Do you normally wear glasses or contacts?
If YES, which do you wear most of the time?
Glasses
Contacts
If YES, how old is the prescription?________________
YES
NO
Do you have a history of any eye disease, eye surgery (including laser
surgery) or eye injuries?
If YES, please list types and dates:
YES
NO
Are your currently taking medications of any type (including vitamins and
supplements)?
If YES, please list:
YES
NO
Are you allergic to any medications?
If YES, please list medications and type of reaction:
YES
NO
Not Applicable
Are you now pregnant or breast feeding?
Medical History: (check box YES or NO. If YES, also note date when first diagnosed.)
Date
YES_______
NO
High Blood Pressure
YES_______
NO
Diabetes
YES_______
NO
Heart Diabetes (congestive heart failure, heart rhythm problem,
heart attack, murmur),
Type: _______________
YES_______
NO
Lung Disease (emphysema, asthma), Type: _______________
YES_______
NO
Liver Disease, Type: _______________
YES_______
NO
Kidney Disease, Type: _______________
YES_______
NO
Gastrointestinal Disease (Crohn’s, ulcerative colitis, peptic ulcer),
Type: _______________
YES_______
NO
Cancer, Type: _______________
YES_______
NO
Stroke or TIA’s
YES_______
NO
High Cholesterol
YES_______
NO
Thyroid Disease
YES_______
NO
Migraines
YES_______
NO
Sleep Apnea
YES_______
NO
Seizures
YES_______
NO
Blood/Bleeding Disorder (anemia, blood transfusion), Type: __________
YES_______
NO
Arthritis, Type:_______________
YES_______
NO
Emotional Illness (anxiety, depression)
YES_______
NO
Cerebral Palsy
YES_______
NO
Prematurity
Please list any other medical problems that you have been diagnosed with:___________________
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