Health History

Drs. Hawks, Besler, Rogers & Stoppel
Param2
Param3
Param4
Param5
Param6
Patient Name

First NameLast Name
Birthdate

MonthDayYear
Date
Primary Care Doctor
Do your eyes water or burn?

YesNo
Do your eyes ever feel dry or gritty?

YesNo
Reason for Visit Please let the doctor know what's going on with your vision. For example, are they dry? Do your contacts bother you? is it hard to focus when driving or reading? Harder to read your phone or computer? Glasses not working as well or need to be "stronger"?
If you ARE NOT experiencing any changes in vision whatsoever, you maylist "EYE EXAM" as a reason for the visit.
Artificial Tears / Non Prescription Eye Drops
If you use artificial tears or non-prescription eye drops, please let us know which brand(s) Skip this question if you do not use such products.
Brand/Type
Electronics or Screen Time
How many hours a day, on average, do you spend on a computer, cell phone or tablet?*

Less than 11 - 2 hours2 - 4 hours4 - 6 hours6 - 8 hours8 - 10 hours10 - 12 hours12 + hours
Current Health Conditions
Please check all of your current health conditions or disorders, eve if they are controlled with mediciations Select "None" if you have no current conditions or disorders

HypertensionHigh CholesterolDiabetes Type 1Diabetes Type 2Acid RefluxArthritisRheumatoid ArthritisGoutAnxietyDepressionBipolarSeasonal AllergiesCrohn's DiseaseHypothyroidism (under active)Hyperthyroidism (Over active)Enlarged ProstateAtrial Fibrillation (Afib)Transient Ischemic Attack (TIA)StrokeHeart DiseaseUlcerative CollitisSquamous Cell CarcinomaBasal Cell CarcinomaAsthmaSleep ApneaNONE
List any conditions not included above
Height / Weight
Height
Weight
Do you drink alcohol socially?

YesNo
Do you smoke tobacco?

YesNo
Please list all of your medications, including supplements
Please list any drug allergies
Eye Color If you are a new patient, please let us know your eye color.
Signature*

Clear
Should be Empty: