Patient Health History

Patient Health History
Name *

First Name Last Name
Date of Birth *

Month Day Year
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:

Cataract Eye Turn Glaucoma Macular Degeneration Retinal Detachment
Please indicate if any of these conditions apply to a Family Member

Cataract Eye Turn Glaucoma Macular Degeneration Retinal 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:
Allergy *

No Concerns Yes-See details listed above
Cardiovascular *

No Concerns Heart Disease High Blood Pressure Stroke
Constitutional (General Health) *

No Concerns Dizziness Fatigue Fever Weight loss / gain
Endocrine *

No Concerns Cholesterol (Elevated) Crohn's Disease Diabetes Pituitary Disorder Thyroid Disorder
Gastrointestinal *

No Concerns Acid Reflux Colitis Ulcer
Genitourinary *

No Concerns Kidney Stones Prostate Disorder STI (Chlamydia, Syphilis, etc.)
Head *

No Concerns Chronic Cough Dry Mouth Headaches Migraines Ringing Ears Sinusitis Trauma
Hematologic / Lymphatic *

No Concerns Anemia Bleeding Disorder Breast Cancer Hodgkin's Disease Leukemia
Immunologic *

No Concerns AIDS Chicken Pox Herpes Simplex (Cold Sores) Herpes Zoster (Shingles) Lyme Disease
Integumentary (Skin) *

No Concerns Acne Acne Rosacea Eczema Lupus Psoriasis
Musculoskeletal *

No Concerns Arthritis Fibromyalgia Osteoporosis Rheumatoid Arthritis
Neurological *

No Concerns Blackouts Dyslexia Epilepsy Fainting Multiple Sclerosis Seizures Tremors
Psychiatric *

No Concerns Alzheimer's Disease Anxiety Attention Disorder (ADD) Autism Bi-Polar Disorder Depression
Respiratory *

No Concerns Asthma Bronchitis Emphysema Lung Cancer Smoker Tuberculosis
Social History
Tobacco Use *
Alcohol Use *
Narcotic Use
Should be Empty:

Patient Health History

Medical / Family History

Review of Systems

Social History