Evergreen Eye Center Medical History Form Page 2
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2Patient Eye History (circle yes for all that apply)
Amblyopia
Yes
Keratoconus
Yes
Blepharitis
Yes
Macular degeneration
Yes
Cancer (in or around eye)
Yes
Muscle surgery
Yes
Cataract
Yes
Ocular trauma
Yes
Cataract surgery
Yes
Refractive Procedure
Yes
Diabetic laser
Yes
(i.e. LASIK, RK, LASEK, PRK)
Double vision
Yes
Retinal detachment
Yes
Dry eyes
Yes
Wandering/lazy eye
Yes
Eyelid surgery
Yes
Other eye disease or surgery: _____________________
Glaucoma
Yes
______________________________________________
Herpes simplex
Yes
______________________________________________
Herpes zoster
Yes
Medications
(Please list all current medications, over-the-counter medications, vitamins, and medication strengths.)
Medications
Strength
Medications
Strength
Allergies
(Please list all allergies to medications and the specific allergic reaction.)
Allergies
Reaction
Allergies
Reaction
Past Surgeries
Surgery
Year
Surgery
Year
Social History (circle yes for any that apply)
Current Occupation:
Alcohol Consumption
Yes
Activities and Hobbies:
(If yes, please specify times per week:
_____)
Smoking Status
Never, Former, Current
(If former, please specify year quit: _______ ____)
Recreational drug use
Yes
(If current, please specify year begun: __________)
(if yes, please specify type:
_____)
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