Ocular Health History Sheet

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Ocular Health History
Patient Name:
Date:
Email Address:
Phone No.
Address:
Job Position:
Employer:
Start Date:
Years:
Screen Time Hours per Day:
Distance from Screen:
Miles Driven per Day:
Day or Night:
Glare Problems while Driving: ¨ Yes
¨ No
Night Vision Problems: ¨ Yes
¨ No
Glasses: ¨ Yes
¨ No
Year Acquired:
Type: ¨ Full-time ¨ Occupational ¨ Reading ¨ Distance ¨ Bifocal ¨ Safety ¨ Athletics
Sunglasses: ¨ Yes
¨ No
Prescription: ¨ Yes
¨ No
Contacts: ¨ Yes
¨ No
Willing to Try Contacts: ¨ Yes
¨ No
Medications:
Allergies:
Pregnant: ¨ Yes
¨ No
Nursing: ¨ Yes
¨ No
Alcohol Use: ¨ Never
¨ Occasionally ¨ Monthly ¨ Weekly ¨ Daily ¨ 4+ per Day
Smoking: ¨ Never
¨ Occasionally ¨ 1 per Day ¨ 1 Pack per Day ¨ 2+ Packs per Day
Illegal Drug Use: ¨ Never
¨ Occasionally ¨ Monthly ¨ Weekly ¨ Daily
Exercise: ¨ Never
¨ Occasionally ¨ Weekly
¨ 2-3 Times per Week ¨ Daily
My History
My Family History
Amblyopia
¨ Yes
¨ No
Amblyopia
¨ Yes
¨ No
Blindness
¨ Yes
¨ No
Blindness
¨ Yes
¨ No
Blurred Vision
¨ Yes
¨ No
Blurred Vision
¨ Yes
¨ No
Burning Sensation
¨ Yes
¨ No
Burning Sensation
¨ Yes
¨ No
Cataracts
¨ Yes
¨ No
Cataracts
¨ Yes
¨ No
Color Blindness
¨ Yes
¨ No
Color Blindness
¨ Yes
¨ No
¨ Yes
¨ No
¨ Yes
¨ No
Diabetic Retinopathy
Diabetic Retinopathy
Distorted Vision
¨ Yes
¨ No
Distorted Vision
¨ Yes
¨ No
Dry Eyes
¨ Yes
¨ No
Dry Eyes
¨ Yes
¨ No
¨ Yes
¨ No
¨ Yes
¨ No
Epiphora
Epiphora
Glaucoma
¨ Yes
¨ No
Glaucoma
¨ Yes
¨ No
Headaches
¨ Yes
¨ No
Headaches
¨ Yes
¨ No
Infection
¨ Yes
¨ No
Infection
¨ Yes
¨ No
Injury
¨ Yes
¨ No
Injury
¨ Yes
¨ No
Itching
¨ Yes
¨ No
Itching
¨ Yes
¨ No
Light Sensitivity
¨ Yes
¨ No
Light Sensitivity
¨ Yes
¨ No
Loss of Vision
¨ Yes
¨ No
Loss of Vision
¨ Yes
¨ No
Mucous Discharge
¨ Yes
¨ No
Mucous Discharge
¨ Yes
¨ No
Redness
¨ Yes
¨ No
Redness
¨ Yes
¨ No
Retinal Detachment
¨ Yes
¨ No
Retinal Detachment
¨ Yes
¨ No
¨ Yes
¨ No
¨ Yes
¨ No
Strabismus
Strabismus
Swelling
¨ Yes
¨ No
Swelling
¨ Yes
¨ No
Tired/Sore
¨ Yes
¨ No
Tired/Sore
¨ Yes
¨ No

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