Patient Health History
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Height
Weight
Hand Preference
*
Right-Handed
Left-Handed
(Certain multifocal options require this information)
Primary Care Physician & Approximate Date Last Seen
Medical / Family History
Please list all of your current medications (include over-the-counter, vitamins and herbal therapy):
List all major surgeries (eye surgery included):
List allergic conditions (medications, seasonal, mold, dust, latex, eye drops):
Please indicate if any of these conditions apply to YOU:
Cataract
Eye Turn
Glaucoma
Macular Degeneration
Retinal Detachment
Other
Please indicate if any of these conditions apply to a Family Member
Cataract
Eye Turn
Glaucoma
Macular Degeneration
Retinal Detachment
Other
Women:
Are you pregnant?
Are you nursing?
Review of Systems
Please indicate below if you have currently or have ever had problems with any of the following conditions. You must address each section - Please select "No Concerns" if none of the conditions in a section pertain to you.
Allergy
*
No Concerns
Yes-See details listed above
Cardiovascular
*
No Concerns
Heart Disease
High Blood Pressure
Stroke
Other
Constitutional (General Health)
*
No Concerns
Dizziness
Fatigue
Fever
Weight loss / gain
Other
Endocrine
*
No Concerns
Cholesterol (Elevated)
Crohn's Disease
Diabetes
Pituitary Disorder
Thyroid Disorder
Other
Gastrointestinal
*
No Concerns
Acid Reflux
Colitis
Ulcer
Other
Genitourinary
*
No Concerns
Kidney Stones
Prostate Disorder
STI (Chlamydia, Syphilis, etc.)
Other
Head
*
No Concerns
Chronic Cough
Dry Mouth
Headaches
Migraines
Ringing Ears
Sinusitis
Trauma
Other
Hematologic / Lymphatic
*
No Concerns
Anemia
Bleeding Disorder
Breast Cancer
Hodgkin's Disease
Leukemia
Other
Immunologic
*
No Concerns
AIDS
Chicken Pox
Herpes Simplex (Cold Sores)
Herpes Zoster (Shingles)
Lyme Disease
Other
Integumentary (Skin)
*
No Concerns
Acne
Acne Rosacea
Eczema
Lupus
Psoriasis
Other
Musculoskeletal
*
No Concerns
Arthritis
Fibromyalgia
Osteoporosis
Rheumatoid Arthritis
Other
Neurological
*
No Concerns
Blackouts
Dyslexia
Epilepsy
Fainting
Multiple Sclerosis
Seizures
Tremors
Other
Psychiatric
*
No Concerns
Alzheimer's Disease
Anxiety
Attention Disorder (ADD)
Autism
Bi-Polar Disorder
Depression
Other
Respiratory
*
No Concerns
Asthma
Bronchitis
Emphysema
Lung Cancer
Smoker
Tuberculosis
Other
Social History
Tobacco Use
*
Never Smoked
Former Smoker
Current Everyday Smoker
Current Some Day Smoker
Heavy Tobacco Smoker
Light Cigarette Smoker (1-9 cigs/day)
Current Smokeless Tobacco User
Current Vape/E-Cig User
Alcohol Use
*
None
Social use only
1-2 drinks daily
More than 2 drinks daily
Narcotic Use
None
Recreational Use
Medical Use
Submit
Should be Empty: