Patient HEALTH History

Patient HEALTH History

Dr. Gerald Matsuda Dr. Stuart Machida Dr. Kari Chang-Moses Dr. Shelley Tasaka Dr. Keith Kawamura
Name *
Reason for Visit: *

Check Up (No Difficulty, Seeing Clearly And Comfortably) Seeing or Eye Problem (Please Explain)
How Long Ago Was Your Last Complete Eye Exam?
Dilated

Yes No
Who Was Your Last Eye Doctor?
Who Is Your Primary Care Physician? *
Do you Wear Glasses

Yes No
How Old Are Your Present Glasses?
Have You Ever Worn Contact Lenses?

Yes No
Do You Currently Wear Contact Lenses?

Yes No Sometimes
State Contact Lens Type *
Please include Brand, Base Curve (B.C.), Diameter (Diam.), Power
If No, Are You Interested In Wearing Contact Lenses?

Yes No Maybe
Are You Currently Taking Any Drugs Or Medications? *

Yes No
Are You Currently Allergic To Any Drugs Or Medications? *

Yes No
Have You Ever Had Any Eye Disease, Eye Injury, Or Eye Surgery?

Yes No
Do You Currently Smoke *

Yes No
Have You Ever Smoked Before?

Yes No
Do You Drink Alcohol? *

Yes No
Do You Use Recreational Drugs? *

Yes No
Height *
Weight *

Do You Have Any Of The Following Problems/Conditions (Please List): *

Yes

Please List

Allergy (Hay Fever, Atopy, Etc.)

Cardiovascular (High Blood Pressure, Cholesterol, Heat Problems Etc.)

Constitutional (Fever, Weight Loss/Gain, Fatigue, Etc.)

Endocrine (Diabetes, Hormone, Thyroid, Etc.)

Gastrointestinal (Hernia, Ulcers, Acid Reflux, Etc.)

Genitourinary (Bladder Infection, Kidney Stones, Prostate, Etc.)

Head (Ears, Nose, Mouth, Throat) (Hearing Loss, Cough, Congestion, Dry Mouth, Etc.)

Hematologic/Lymphatic (Anemia, Blood Disorder, Bleeding Problems, Etc.)

Integumentary (Skin, Rashes, Acne, Eczema, Etc.)

Musculoskeletal (Arthritis, Joint, Osteoporosis, Etc.)

Neurological (Multiple Sclerosis, Headaches, Migraines, Etc.)

Psychiatric (Anxiety, Depression, ADHD, Bi-Polar, Etc.)

Respiratory (Asthma, Emphysema, Bronchitis, Etc.)

Currently Pregnant/Nursing

Do You Have Any Family History of: (Please List Family Member)

List Family Member

Amblyopia

Blindness

Cataracts

Eye Surgery

Glaucoma

Macular Degeneration