huxleyvisionclinic.com-Patient History Questionnaire

Patient History Questionnaire
Name

First NameLast Name
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for today's visit
Do you wear contacts or glasses?

GlassesContactsBoth
DOB:

MonthDayYear
Date
Are you planning on updating your eyewear ?

GlassesContactsBoth
Cell No:
How did you hear about our clinic?
Employer
Referred by:
SSN:
Email
example@example.com
Eye Health and Medical History
Date of last eye exam:

MonthDayYear
Date
Date of last physical exam :

MonthDayYear
Date
Primary Care Provider:
Please check any of the following conditions you have or have had in the past

Blurred Vision - DistanceEye SurgeryEye StrainBlurred Vision - NearLoss of VisionDouble VisionFlashes of Light FloatersPoor Night VisionCataractsDry EyesGlaucomaRetinal DiseasePoor Color VisionEye InfectionHeadachesSensitivity to LightCrossed / Lazy EyeEye InjuryItchy, Watery EyesOther
Other
Please check all that apply if any of your blood relatives has any of the following and and their relationship to you

CataractsMacular DegenerationDiabetesRetinal DetachmentGlaucomaOther
Relationship
Other
Please check any of the following conditions you have or have had in the past

AIDS/HIVCholesterolHigh Blood PressureShinglesArthritisDiabetes (Type)Kidney DiseaseStrokeAsthmaEczema / RosaceaMigraine HeadachesThyroid ProblemsBlood DisordersEpilepsyMultiple SclerosisTobacco UseCancer (Type)Heart DiseasePregnant NursingTuberculosisChemical DependencyHepatitis (Type)Seasonal AllergyOther (Type)
Other
Medications
Prescribed or OTC (including eye drops)
Allergies
Please list your allergies to medications or substances
Life Style
Occupation
Do you........

Spend a lot of time outdoorsCurrently have prescription sun wearUse a computer on a daily basis, hours/daysCurrently have computer eyewearSpend lots of time reading / close up workHave an interest in daily disposable contact lensesWant information on laser vision correction
Hours/days
Should be Empty:

Patient History Questionnaire

Eye Health and Medical History

Medications

Allergies

Life Style