Patient Health History Form
Patient Name:
Date:
/
Month
/
Day
Year
Date
Reason for visit:
Age:
Date of Birth:
/
Month
/
Day
Year
Date
Sex:
Male
Female
Physician/Provider:
What Pharmacy do you use?
Tobacco?
Smoke
Never
Vape/E-Cig
Chew
Former
Recreational Drug Use?
No
Yes
If yes, what type?
Medications you are allergic to:
Latex Allergy?
Yes
No
Iodine Allergy?
Yes
No
Adhesives Allergy?
Yes
No
Current Medications and Supplements:
Eye Medications:
PAST MEDICAL HISTORY: Check all that apply
Asthma
Epilepsy/Seizures
Kidney/Liver Disease
Depression
Anxiety
High Blood Pressure
High Cholesterol
Diabetes
Blood Clots
Heart Disease
Thyroid Disease
Osteoporosis
Migraines
EYE HEALTH HISTORY:
Any Surgeries?
No
Yes
What type of surgery?
Glaucoma:
Self
Family
Lazy Eye/Lazy Sighted
Self
Family
Macular Degeneration:
Self
Family
Other
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