Patient History Form Page 2
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2Review of Systems: Please indicate any condition that applies to you with a check mark.
NONE
Cardiovascular
Immunologic
Neurological
High Blood Pressure
Rheumatoid arthritis
Headaches
High Cholesterol
Lupus
Multiple Sclerosis
Heart Attack
Sjogren’s Syndrome
Myasthenia Gravis
Pacemaker
Histoplasmosis
Psychiatric
Constitutional
Integumentary/Skin
Depression
Dizziness
Eczema
Panic Disorder/Schizophrenia
Excess Thirst
Rosacea
Drug Dependence
Excess Urination
Psoriasis
Respiratory
Weight Gain / Weight Loss
Skin Cancer
Asthma
Endocrine
Liver / Lymph System
COPD
Diabetes
Anemia
Lung Cancer
Thyroid Dysfunction
Leukemia
Sarcoidosis
Pituitary Dysfunction
Musculoskeletal
Other:
Gastrointestinal
___________________________
Arthritis
Crohn’s Disease
Fibromyalgia
___________________________
Hepatitis
Family History:
Diabetes
High Blood Pressure
Heart Problems
Cancer
Respiratory Problems
Thyroid Problems
Headaches
Please specify whom_____________________________________________________________________________________________________________
Family Eye History:
Cataracts
Glaucoma
Retinal Detachment
Macular Degeneration
Eye Surgery
Lazy Eye
Other
Please specify whom_____________________________________________________________________________________________________________
For Contact Lens Wearers…
Contact lens evaluation and fitting:
Contact lens patients require additional testing and monitoring over and above what is done during a routine eye exam. Contact
lenses are medical devices and even though they may feel fine, there are health risks that must be taken seriously. In order to
renew your contact lens prescription, your doctor performs the following tests on a yearly basis. These procedures are not part of
a standard eye exam.
• Slit lamp microscope examination of the contact lens on the eye to check the lens fit.
• Slit lamp microscope examination of the cornea, conjunctiva and eyelid tissues, to check the eye health and to look for adverse
effects from contact lens wear.
• Contact lens refraction to determine the correct contact lens prescription power (contact lens prescriptions are different than
eyeglass prescriptions).
• We also review new lens designs, materials and cleaning solutions that may improve comfort and/or health.
Some insurances may cover some of the cost of the contact lens evaluation fee. If you have never worn contact lenses, there
is an additional training fee. Contact lens fittings start at $71.
For All Patients…
Acknowledgement of HIPAA Policies:
I acknowledge that I have received a copy of the Notice of Privacy Practices.
Signature__________________________________________ Date______/______/______
Acknowledgement of Financial Policies:
I hereby authorize North Valley Eye Care, P.C. to release information that is required by my insurance carrier.
I acknowledge that I am financially responsible for all non-covered charges.
Signature___________________________________________Date______/______/_____
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