Patient Health History

Patient Health History
Name *

First Name Last Name
Date of Birth *

Month Day 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:

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. 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
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