Health History

PATIENT HISTORY
Patient Name:*
DOB*

MonthDayYear
Gender*

MF
Race*
Ethnicity*
Preferred Language*
How do you prefer that we contact you?*

EmailPostalPhoneText
Primary Care Physician:*
Date Last Seen:*

MonthDayYear
Last Eye Exam

MonthDayYear
Medical/Family History
Please list all your current medications (include prescriptions, over the counter, vitamins and herbal therapies):*
Please list all current eye drops*
List all major surgeries (Eye Surgery included):*
List any allergic reactions to medications or eye drops:*
Please indicate if any of the conditions apply to you or a family member (blood relatives only).

Disease/Condition For Yourself
Cataract*

YesNo
Eye Turn*

YesNo
Glaucoma*

YesNo
Macular Degeneration *

YesNo
Retinal Detachment*

YesNo
Women- Are you pregnant?

YesNo
Are you breast feeding?*

YesNo
Disease/Condition For Family Member
Blindness*

YesNo
Relationship (Blood Relatives Only)*
Eye Turn*

YesNo
Relationship (Blood Relatives Only)*
Glaucoma*

YesNo
Relationship (Blood Relatives Only)*
Macular Degeneration *

YesNo
Relationship (Blood Relatives Only)*
Retinal Detachment*

YesNo
Relationship (Blood Relatives Only)*
Other:
Review of Systems. Please indicate below if you have or ever had problems with the following conditions:
Allergic/Immunologic

NoneLupus (SLE)Rheumatoid ArthritisEnvironmental AllergiesSeasonal AllergiesOther (i.e., Latex)
Ear, Nose and Throat

NoneSinusitisUpper Respiratory Tract InfectionOther
Gastrointestinal

NoneCrohn's DiseaseColitisAcid Reflux/UlcerOther
Skin /Integumentary

NoneEczemaRosaceaPsoriasisOther
Psychiatric

NoneDepressionBi-PolarSchizophreniaOther
Cardiovascular

NoneHigh Blood PressureHeart DiseaseStrokeVascular DiseaseHigh Blood Cholesterol
Endocrine/Glands

NoneDiabetesHormone DysfunctionThyroid DysfunctionOther
Respiratory

NoneAsthmaBronchitisEmphysemaOther
Muscle/Skeletal

NoneArthritisFibromyalgiaAnkylosing SpondylitisOther
Genital/Urinary

NoneUrinary Tract InfectionHIV PositiveHerpes/ChlamydiaOther
Hematologic/Lymphatic

NoneAnemiaLeukemiaBleeding DisorderOther
Neurological

NoneMultiple SclerosisEpilepsyMemory problemsOther
General Health

NoneWeight loss/gainFeverFatigueTrauma
Social
Tobacco Use:*

YesNo
Are you Current Smoker or Former Smoker?*

Current SmokerFormer Smoker
Type*

TobaccoVapingMarijuanaOther
Non-Prescription Drugs
Alcohol Consumption

YesNo
How often do you drink?*
Weight*
Height*
Please sign below to acknowledge that this form is current:
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Date:*

MonthDayYear
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PATIENT HISTORY

Medical/Family History

Disease/Condition For Yourself

Disease/Condition For Family Member

Social