Patient Ocular And Medical History Form

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Patient Ocular and Medical History
Patient Name: _______________________________________
 Male  Female
Date: ________________
Name of Primary Care Physician:___________________________________ Phone #____________________________
Other Medical Doctor(s): ____________________________________________________________________________
Last Eye Exam: Date: __________________ Location: ______________________ Doctor: ______________________
Personal Medical History:
Do you have any allergies to medications?  Yes  No If yes, list: __________________________________________
Do you have any seasonal/food allergies?  Yes  No If yes, list: __________________________________________
Are you pregnant?  Yes  No
List all Medications (Prescription/Over the Counter):
Name
Dosage
Reason
1.
2.
3.
4.
5.
6.
7.
8.
List all major injuries, surgeries, and/or hospitalizations you have had: ________________________________________
_________________________________________________________________________________________________
List any eye surgeries: ______________________________________________________________________________
Have you ever been diagnosed with:
YES
NO
YES
NO
Diabetes
Glaucoma
Heart Disease
Cataracts
High Blood Pressure
Retinal Detachment
High Cholesterol
Eye Injury
Stroke
“Lazy Eye”
Cancer ______________________ 
Diabetic Eye Disease
Thryoid Disease
Thyroid Eye Disease
Multiple Sclerosis
Macular Degeneration
HIV/AIDS
Other ________________________________
Migraines
_____________________________________
Asthma/Ephysema (please circle)
Family Medical History: Has anyone in your family had: (if yes please list relationship to you)
YES
NO
Macular Degeneration
 ______________________________________________
Glaucoma
 ______________________________________________
“Lazy Eye”
 ______________________________________________
Cataracts
 ______________________________________________
Diabetes
 ______________________________________________
High Blood Pressure
 ______________________________________________
Heart Disease
 ______________________________________________
Other ___________________________
 ______________________________________________
(OVER)

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