Patient History Form Page 2
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2Palos Verdes Family Vision Optometry
Patient History Form
Family Physician Name:
City:
Phone:
Eye Symptoms/Conditions
Headaches
Excess Tearing/Watering
Blurred Distance Vision
Glare/Light Sensitivity
Eye Pain/Soreness
Blurred Near Vision
Tired Eyes
Sandy/Gritty Feeling
Fluctuating Vision
Amblyopia/Lazy Eye
Foreign Body Sensation
Glaucoma
Burning
Mucous Discharge
Cataracts
Dryness
Double Vision
Retinal Detachment
Itching
Intermittent Vision Loss
Macular Degeneration
Redness
Floaters/Spots
Eye Injury or Surgery
Indicate any personal history below:
Cardiovascular
Integumentary
Musculoskeletal
Heart Disease
Acne Rosacea
Arthritis
Cholesterol, Elevated
Lupus
Rheumatoid Arthritis
High Blood Pressure (Hypertension)
Psoriasis
Neurological
Stroke
Head/ENT/Dental
Bell’s Palsy
Endocrine
Chronic Cough
Brain Tumor
Diabetes
Migraines
Multiple Sclerosis
Gout
Sinusitis
Parkinson’s Disease
Hypo/Hyperthyroidism
Dizziness
Seizures
Renal Disorder (Kidney)
Allergies
Psychiatric
Gastrointestinal
Hematologic/Lymphatic
Alzheimer’s
Colitis
Leukemia
Bi-Polar Disorder
Hepatitis
Lymphatic Disorder
Depression
Inflammatory Bowel Disease
Sickle Cell Disease
Learning Disability
Genitourinary
Temporal Arteritis
Schizophrenia
Menopause
Immunologic
Respiratory
Breast Cancer
AIDS
Asthma
(Diagnosis year:_____)
Pregnant or Nursing
Sarcoidosis
COPD
Other
Sjogren’s Syndrome
Emphysema
Cancer (Type): ________________
Syphillis
Lung Disease
Other: _______________________
Tuberculosis
Lung Cancer
(Diagnosis year:______)
Family History:
Relationship to Patient
Relationship to Patient
Amblyopia/Lazy Eye
Cancer
Type: ___________
Blindness
Diabetes
Cataracts
Heart Disease
Glaucoma
Stroke
Retinal Detachment
Thyroid Disease
Macular Degeneration
High Blood Pressure
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