Patient'S Medical History Form

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PATIENT’S MEDICAL HISTORY FORM
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Do you suffer from or have been treated for any of the following?
Please check any that pertain to you
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Blurred Vision, Distance
Tearing/Watering eye(s)
Corneal Abrasions
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Blurred Vision, Near
Burning
Eye Injury
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Blurred Vision, Night
Discharge
Iritis/Uveitis
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Blurred Vision, Computer Distance
Vision or Field of Vision Loss
Cataracts
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Contact lens discomfort
Flashes of Light
Glaucoma
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Light Sensitivity
Floaters/Spots
Macular Degeneration
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Eye Strain/Fatigue
Halos
Retinal Detachment
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Double Vision
Crossed eye/Turned eye
Color Deficiency
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Itchiness
Eye Infections
Diabetic Retinopathy
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Grittiness/Scratchy
Bump on Eye Lid(s)
Keratoconus
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Dryness
Headaches/Migraines
Eye Surgeries
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Redness
Ocular Allergies
Other:______________________
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Anxiety
Coronary Artery Disease
Hyperthyroidism
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Arthritis
Depression
Hypothyroidism
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Asthma
Diabetes
Leukemia
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Atrial Fibrillation(Irregular Heartbeat)
End Stage Renal Disease
Lymphoma
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Bone Marrow Transplantation
GERD
Prostate Cancer
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BPH
Hearing Loss
Radiation Treatment
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Breast Cancer
Hepatitis
Sleep Apnea
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Colon Cancer
HIV/AIDS
Seizures
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COPD
Hypercholesterolemia
Stroke
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Other:_______________________
Are you using eye drops?
Y___
N ___
If yes, what type? ________________________ How often? __________________
Please list all Prescribed and Over the Counter Medications, including Eye Drops, vitamins and supplements, you are currently taking
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if you have a list please give it to the receptionist to make a copy
Name of Prescription/Medication
Taken for what Condition
Dosage
Frequency
Please list all Medications you are Allergic to:
Name of Medication
Reaction
Name of Medication
Reaction
Is there a Family Medical History of any of the following?
Relationship
Relationship
Relationship
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High Blood Pressure _____________
Glaucoma
___________
Heart Disease
____________
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Diabetes
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Cataracts
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Retinal Problems ____________
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Cancer
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Macular Degeneration___________
Corneal Problems ____________
Primary Care Provider (PCP) __________________________________ Referring Provider __________________________________
Social History: Use of Tobacco/Alcohol
Are you currently a smoker? Yes___ No___ Have you been a smoker in the past? Yes___ No___
Do you drink Alcohol? Yes___ No___ If so, how many glasses a day? _____

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