Patient HEALTH History

Patient HEALTH History

Dr. Gerald Matsuda Dr. Stuart Machida Dr. Kari Chang-Moses Dr. Shelley Tasaka Dr. Jenny Nguyen
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

YesNo
Who Was Your Last Eye Doctor?
Who Is Your Primary Care Physician?*
Do you Wear Glasses

YesNo
How Old Are Your Present Glasses?
Have You Ever Worn Contact Lenses?

YesNo
Do You Currently Wear Contact Lenses?

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

YesNoMaybe
Are You Currently Taking Any Drugs Or Medications?*

YesNo
Are You Currently Allergic To Any Drugs Or Medications?*

YesNo
Have You Ever Had Any Eye Disease, Eye Injury, Or Eye Surgery?

YesNo
Do You Currently Smoke*

YesNo
Have You Ever Smoked Before?

YesNo
Do You Drink Alcohol?*

YesNo
Do You Use Recreational Drugs?*

YesNo
Height*
Weight*

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

	Yes	No	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)

I ACKNOWLEDGE THAT I RECEIVED A COPY OF WINDWARD VISION CENTER’S NOTICE OF PRIVACY PRACTICES.
Signature*

Please sign. Clear
Date

MonthDayYear
Date
Phone Number

Area CodePhone Number
46-056 Kamehameha Highway., Kaneohe, HI 96744, Ph. (808) 235-6641

30 Aulike Street, Suite 102, Kailua, HI 96734, (808) 262-8107
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