Medical Health History

John L. Bonner Eye Clinic would like to welcome you to our office.

Enclosed is a registration form and a medical history questionnaire for you to complete. Please bring the completed forms, along with your current insurance card and a photo ID with you to your appointment. Many insurance plans require referrals before they will pay for medical services. If referrals are required, it is your responsibility to get the referrals in place prior to your office visit. If you are uncertain as to whether or not you need a referral, please refer to your member handbook or call your insurance company. The phone number should be found on the back of your insurance identification card.

Many insurance plans require you to make a co-pay with each office visit. Your co-pay is due at the time of your visit.

Your eyes will be dilated for most types of exams, so plan to bring a driver. The effects of the dilation can last up to several hours or even into the next day.

Please bring a list of all your medications, including eye drops, to your appointment.

If you have any questions or need clarification, please call the office where your visit will take place. In addition, please feel free to visit our new website at www.bonnereyeclinic.com.

Thank you for choosing the John L. Bonner Eye Clinic as your ophthalmology clinic. The physicians and staff at our clinics are committed to providing you with high quality care in an efficient and compassionate environment.
Patient's Name*
Date of Visit

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Date of Last Eye Exam

MonthDayYear
Date
List any eye medications/eye drops you currently use and the strength*
List any allergies to medications and reactions*
List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack,etc.) or injuries (concussion, etc) *
List any eye surgeries you have had (cataract, LASIK, etc.) & approximate date*
List any other surgeries you have had (tonsillectomy, appendectomy, stents, pacemaker, cancer) & approximate date*
History of excessive scarring (keloids)?*

YesNo
Alcohol consumption*

NoneOccasionallyDrinks RarelyDrinks SociallyHeavy DrinkerQuit Drinking
Smoking habits*

Former SmokerNever SmokedCurrent SmokerQuit SmokingUses Other tobacco Products (chew, Cigar)
Current occupation*
Living Arrangements*
Do you drive*

DrivesDrives occasionallyDoes not driveDoes not drive at nightNo license
Have you ever tried to wear contact lenses?*

YesNo
What kind of contacts?

Soft LensesHard Lenses
What is your average wearing time in hours?
What solution cleaner do you use?
Do you currently wear contact lenses?*

YesNo
How long?
Do you currently wear glasses?*

YesNo
How long have you had your current prescription?

Do you currently have any eye problems in the following areas? If YES, please provide information. *

	Yes	No	Details
Loss of vision
Blurred vision
Fluctuating vision
Distorted vision (halos)
Glare of light sensitivity
Visual difficulty when driving
Problems with night vision
Loss of side vision
Double vision
Dryness
Mucous discharge
Redness
Sandy or gritty feeling
Itching
Burning
Foreign body sensation
Excess tearing or watering
Eye pain or soreness
Tired eyes
Crossed eyes, lazy eyes
Drooping eyelid

Do you currently have any of the following general health conditions?*

	Yes	No	Details
GENERAL/CONSTITUTIONAL (fever, weight loss, other)
INTEGUMENTARY (eczema, lupus ,psoriasis, rahses)
EARS, NOSE, THROAT (hearing aides, stuffy nose, ear ache, cough, dry mouth, etc.)
CARDIOVASCULAR (high blood pressure, high cholesterol, arrhythmia, heart attack, etc)
RESPIRATORY (congestion, wheezing, COPD, Hx of TB, lung issues, etc)
GASTROINTESTINAL (acid reflux, GERD, stomach upset, diarrhea, constipation, etc.)
GENITAL, KIDNEY, BLADDER (painful urination, frequent urination, incontinence, prostate canger, etc.)
MUSCLES, BONES, JOINTS (joint pain, stiffness, swelling, cramps, rheumatoid arthritis, gout, etc.)
NEUROLOGICAL (seizures, strokes, headaches, confusion, bells palsy, etc.)
ENDOCRINE (Diabetes (date of diagnosis), thyroid disease, etc.)
PSYCHIATRIC (anxiety, depression, ADHD, ADD, insomnia, etc.)
ALLERGIC/IMMUNOLOGIC (peanuts, bee stings, shellfish, etc.)

FAMILY HISTORY - M=mother, F=father, S=sibling, GP=grandparent*

	YES	NO	RELATIONSHIP TO PATIENT
Blindness
Glaucoma
Cataract
Age-related macular degeneration
Arthritis
Cancer
Diabetes
Heart Disease
High blood pressure
Stroke
Thyroid disease
Other

Patient's Signature

Clear
Date

MonthDayYear
Date
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