eyeinnovations.net - Medical History Form

MEDICAL HISTORY FORM
Referring/Primary Care Doctor:
Phone:
Please enter a valid phone number.
CHIEF COMPLAINT: HOW CAN WE HELP YOU TODAY?
In this space, please briefly tell us any symptoms you are experiencing. (Please note: medical insurance cover visits ONLY if there is a medical reason for the exam such as loss of vision, headaches, eye pain, eye itching or burning, glaucoma, cataracts, floaters, dry eyes, etc.)
HISTORY OF PRESENT ILLNESS
Which eye has the problem (without glasses)?

RightLeftBoth
Does the problem cause vision loss or blur?

LossBlur
Did the problem occur suddenly or gradually?

SuddenlyGradually
How severe is the problem?

MildModerateSevere
Is it worse at any specific distance?

DistanceNearBoth
How long does the problem last?

Comes and goesConstant
How long has the problem been occurring?

Short termLong term
Does anything help the problem?

YesNo
Are there any associated symptoms?

YesNo
REVIEW OF SYSTEMS

Do YOU have or have YOU ever had difficulty in any of the following body systems?
Cardiovascular (high blood pressure)

YesNo
Ears, nose, throat, (allergy, sinus)

YesNo
Infectious disease (HIV, hepatitis)

YesNo
Respiratory (asthma, emphysema)

YesNo
Gastrointestinal (ulcer, colitis, Crohn’s)

YesNo
Genitourinary(genitals, kidneys, bladder)

YesNo
Constitutional (fever, weight loss)

YesNo
Neurological (headaches, seizure)

YesNo
Psychiatric (depression, anxiety)

YesNo
Endocrine (diabetes, thyroid)

YesNo
Musculoskeletal (arthritis)

YesNo
Hematologic (anemia, bleeding)

YesNo
Integumentary (eczema, rosacea)

YesNo
Are you currently pregnant?

YesNo
MEDICATIONS/ ALLERGIES
Do you take any prescription or over the counter medications now?

YesNo
If yes, please list below
Are you allergic to prescription or over the counter medication?

YesNo
If yes, please list below
PAST, FAMILY AND SOCIAL HISTORY
Is there anything in your past, family, or social history which would help us care for you?
PAST:
Injuries:

YesNo
Surgery:

YesNo
FAMILY:
Diseases:

YesNo
GENETIC FACTORS:

YesNo
SOCIAL:

Do you use?
Tobacco

YesNo
Alcohol

YesNo
Recreational Drugs

YesNo
Patient Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Indicate if history was completed by:

PatientSpouseParentChildCaregiverOther
Should be Empty:

MEDICAL HISTORY FORM

CHIEF COMPLAINT: HOW CAN WE HELP YOU TODAY?

HISTORY OF PRESENT ILLNESS

REVIEW OF SYSTEMS

MEDICATIONS/ ALLERGIES

PAST, FAMILY AND SOCIAL HISTORY