Health History Form
Your care and attention to these questions is both necessary and appreciated.
Patient's Name
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First Name
Last Name
Patient's Date of Birth
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Month
-
Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Do you currently: ( check all that apply)
Use prescription glasses
Use contact lenses
Use Over the Counter reading glasses
Desire to try contacts for the first time
Please briefly describe any concerns with your vision and/or eye health:
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Do you currently use any medications?
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No, I do not use any medications
Yes, I do use medications
Please list all the medications you currently take. Do not worry about dose.
Do you now, or have you ever taken: ( Check all that apply)
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hydroxychloroquine/Plaquenil
amiodarone
tamoxifen
None of the above
Regarding hydroxychloroquine/Plaquenil:
I am currently using this medication.
I have used this medication in the past, but do not use it currently.
Regarding amiodarone:
I am currently using this medication.
I have used this medication in the past, but do not use it currently.
Regarding tamoxifen:
I am currently using this medication.
I have used this medication in the past, but do not use it currently.
Do you have any medication allergies:
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No, I have no known medication allergies.
I am allergic to certain medications.
Please list medications to which you are allergic.
Smoking status?
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Never Smoked
Former Smoker
Current Smoker
Do you drink alcohol?
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Never
Socially/Occasionally
Regularly
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If female and of childbearing age:
I am or could be pregnant, planing/trying, or nursing.
I am not pregnant, the above do not apply.
Have YOU had any of the following eye conditions:
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Eye surgery
Serious Eye Injury
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment
Strabismus (Eye Misalignment)
Amblyopia ("Lazy Eye" - uncorrectable decreased vision)
Color vision deficiency
NONE of these apply.
Other
Have YOUR BLOOD RELATIVES had any of the following eye conditions:
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Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment
Strabismus (Eye Misalignment)
Amblyopia ("Lazy Eye" - uncorrectable decreased vision)
Color vision deficiency
NONE of these apply.
Other
Have YOU had any of the following health conditions:
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Diabetes
Rheumatoid Arthritis
Lupus
Heart Attack/ Heart Disease
Stroke/TIA
High Blood Pressure
High Cholesterol
Neurologic Problems
Inflammatory Bowel Disease
Thyroid disease
NONE of these apply.
Other
Please list any surgeries and/or other health conditions:
Primary Care Physician (name and location)
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If you are over 18, we cannot disclose any medical information, even to family members, without your consent. We will not discuss any specifics about your visit with any family members not listed here. Please list any family members or caregivers ( Ex. spouse, parent, adult child) with whom we may discuss the specifics of your visit, including any health conditions. Please list name, date of birth, and relationship.
Examining the inside of the eye is an important part of an eye health exam. Traditionally, this has been done using pupillary dilation, for which there is no additional charge. While most people feel safe to drive, the dilation causes light sensitivity and makes near vision blurry, and some people prefer to avoid driving. We offer OPTOMAP retinal imaging, which is clinically comparable to dilation in most cases, and avoids the side effects. The out of pocket cost for this optional service is $30. We strongly recommend either dilation or OPTOMAP.
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I would prefer the OPTOMAP if appropriate. I understand the fee.
I would prefer to dilate. I will not use driving as an excuse to avoid.
I refuse both dilation and the OPTOMAP. I will sign a waiver at the office.
Patients trying contacts for the first time will not have adequate time for dilation the initial fitting visit. Patients may choose Optomap or may plan to dilate at a their contact lens follow-up visit.
I understand that dilation is not an option at the same visit as a new wearer contact lens fit.
Dilating drops are particularly important for children age 10 and younger, as they help us obtain the most precise glasses prescription, as well as allowing a thorough examination of the retina. For this reason, the drops are STRONGLY RECOMMENDED for young children.
I consent to dilation for my child.
I refuse dilation, and will sign a waiver at the office.
I certify this information is correct and complete to the best of my knowledge.
Clear
Name of Person Signing if other than patient.
First Name
Last Name
Relationship of Person signing if other than patient.
Submit
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