Evergreen Eye Center Medical History Form

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MEDICAL HISTORY FORM
Patient’s Name: _____________________________________
Date of Birth: __________________
Patient Medical History (circle yes for all that apply)
High blood pressure
Yes
Pacemaker, stent
Yes
High cholesterol
Yes
Heart conditions
Yes
Heart conditions
Yes
(If yes, please specify type: ______________)
Stroke
Yes
Cancer
Yes
Emphysema
Yes
(If yes, please specify type: _______________)
Asthma
Yes
Arthritis
Yes
Dementia/Alzheimer’s
Yes
(If yes, please specify type: _______________)
Kidney disease
Yes
Diabetes
Yes
Anemia
Yes
(If yes, please specify type: _______________)
Lupus
Yes
(Last A1C: ________ Last Blood Sugar: ______)
Multiple sclerosis
Yes
Sjogren’s
Yes
Thyroid disease
Yes
Other medical conditions:
HIV
Yes
________________________________________________
Hepatitis B or C
Yes
________________________________________________
MRSA
Yes
________________________________________________
Tuberculosis
Yes
________________________________________________
Neurofibromatosis
Yes
________________________________________________
Bleeding disorder
Yes
Family History (circle yes for all that apply)
Amblyopia
Yes
Thyroid
Yes
Glaucoma
Yes
Hypertension
Yes
Corneal disease
Yes
Stroke
Yes
Keratoconus
Yes
Heart conditions
Yes
Corneal Transplant
Yes
(If yes, please specify type: ______________)
Macular Degeneration
Yes
Diabetes
Yes
Diabetic Retinopathy
Yes
(If yes, please specify type: _______________)
Retinal Detachment
Yes
Cancer
Yes
Retinitis Pigmentosa
Yes
(If yes, please specify type: _______________)
Other Eye Problems:
Other medical conditions:
_______________________________________
____________________________________________
_______________________________________
____________________________________________
(Please turn over page to continue on side 2)
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