Patient Health History

Patient Health History
Name*

First Name Last Name
Date of Birth*

MonthDay Year
Date
Height
Weight
Hand Preference*
(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:

CataractEye TurnGlaucomaMacular DegenerationRetinal Detachment
Please indicate if any of these conditions apply to a Family Member

CataractEye TurnGlaucomaMacular DegenerationRetinal Detachment
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 ConcernsYes-See details listed above
Cardiovascular*

No ConcernsHeart DiseaseHigh Blood PressureStroke
Constitutional (General Health)*

No ConcernsDizzinessFatigueFeverWeight loss / gain
Endocrine*

No ConcernsCholesterol (Elevated)Crohn's DiseaseDiabetesPituitary DisorderThyroid Disorder
Gastrointestinal*

No ConcernsAcid RefluxColitisUlcer
Genitourinary*

No ConcernsKidney StonesProstate DisorderSTI (Chlamydia, Syphilis, etc.)
Head*

No ConcernsChronic CoughDry MouthHeadachesMigrainesRinging EarsSinusitisTrauma
Hematologic / Lymphatic*

No ConcernsAnemiaBleeding DisorderBreast CancerHodgkin's DiseaseLeukemia
Immunologic*

No ConcernsAIDSChicken PoxHerpes Simplex (Cold Sores)Herpes Zoster (Shingles)Lyme Disease
Integumentary (Skin)*

No ConcernsAcneAcne RosaceaEczemaLupusPsoriasis
Musculoskeletal*

No ConcernsArthritisFibromyalgiaOsteoporosisRheumatoid Arthritis
Neurological*

No ConcernsBlackoutsDyslexiaEpilepsyFaintingMultiple SclerosisSeizuresTremors
Psychiatric*

No ConcernsAlzheimer's DiseaseAnxietyAttention Disorder (ADD)AutismBi-Polar DisorderDepression
Respiratory*

No ConcernsAsthmaBronchitisEmphysemaLung CancerSmokerTuberculosis
Social History
Tobacco Use*
Alcohol Use*
Narcotic Use
Should be Empty:

Patient Health History

Medical / Family History

Review of Systems

Social History