Family Eye Care Labelle - Health History Form
Patient Name
*
Birthdate
*
-
Month
-
Day
Year
Email
Have you visited our office before?
Yes
No
Current Occupation
Do you use a computer?
Yes
No
If yes, how many hours/day?
Do you drive?
Yes
No
Do you have any problems driving?
Yes
No
If yes, please explain
Do you have problems with night vision?
Yes
No
Do you wear glasses?
Yes
No
If yes, how old are they?
Do you wear contact lenses?
Yes
No
If yes, what brand are they?
If you have your contact lenses inserted, how old are they?
Are you interested in trying contact lenses if you do not wear them?
Yes
No
Do you wear sunglasses?
Yes
No
If yes, how old are they?
Chief Complaint
Medical History
Family Doctor Name
Family Doctor Phone
-
Area Code
Phone Number
Date of last physical examination
-
Month
-
Day
Year
Date of last eye exam
-
Month
-
Day
Year
Were you dilated?
Yes
No
Height
Weight
Please list any medications, dosages, frequency and why you take them
List all major illnesses, injuries, or surgeries
Do you have any drug allergies?
Yes
No
If yes, please list
LASIK Surgery
Yes
No
Date
-
Month
-
Day
Year
Cataract Surgery
Yes
No
Date
-
Month
-
Day
Year
Retinal Surgery
Yes
No
Date
-
Month
-
Day
Year
Eye History
Please check all of the following conditions you experience.
Headaches
Glare/Light Sensitivity
Tired Eyes
Amblyopia
Burning
Dryness
Epiphora (Excess Tearing/Watering)
Eye Pain or Soreness
Foreign Body Sensation
Infection of Eye or Lid (Blepharitis, Stye)
Itching
Mucous Discharge
Ptosis (Drooping Eyelid)
Redness
Sandy or Gritty Feeling
Strabismus (Crossed Eye)
Blurred Vision Distance
Blurred Vision Near
Distorted Vision (Halos)
Double Vision
Floaters or Spots
Fluctuating Vision
Loss of Vision
Loss of Side Vision
If you marked any of the above conditions or have a condition not listed, please explain below
Please list any eyedrops/eye ointments, dosages, frequency and why you take them
Eyedrops/eye ointments, dosages
Frequency
Why you take
1
2
3
4
5
Do you have or have a family history of
Amblyopia (Lazy Eye)
Blindness
Cataract
Color Blindness
Corneal Disease
Glaucoma
Macular Degeneration
Retinal Detachment
Retinal Disease
Strabismus (Eye Turn)
Other
Please explain if Other
What are your relationships to the family members with the above conditions?
Review of Systems
Do you currently, or have you or any family member ever had any problems in the following areas?
Fever, Weight Loss/Gain
Skin Problems
Headaches
Migraines
Seizures
Thyroid/Other Glands
Allergies/Hay Fever
Sinus Congestion
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Throat/Mouth
Asthma
Chronic Bronchitis
Emphysema
Diabetes
Heart Pain
High Blood Pressure
Vascular Disease
Diarrhea
Constipation
Kidney/Bladder
Rheumatoid Arthritis
Muscle Pain
Joint Pain
Anemia
Allergic/Immunologic
Psychiatric
If you marked any of the above conditions or have a condition not listed, please explain below.
If diabetic, what was your last blood sugar
A1C
Social History
Do you drink alcohol?
Yes
No
If so, how much?
None
Social use only
1-2 drinks daily
3-4 drinks daily
4+ drinks daily
Alcohol Dependent
Tobacco Use?
Yes
No
If so, how much?
Never Smoked
Former Smoker
Current Everyday Smokey
Smokes some days
Current Smokeless Tobacco User
Stopped Smoking?
Yes
No
When?
Within Last Year
1-2 Years
3-4 Years
4-5 Years
5+ Years
10+ Years
Do you have any special hobbies?
Submit
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