PATIENT HEALTH AND HISTORY FORM

Date: ________________________ Chart Number: _______________________

Patient’s Name: ________________________________________________________Date of Birth: ___________________

Primary Care Doctor: _________________________Facility: ____________________ Phone #: ______________________

Date of Last Medical Exam/Physical: _________________

Name of Previous Eye Doctor: ________________________ Facility: __________________ Last Eye Exam: __________

Height: ______Feet _______Inches Weight: ___________lbs

Are you a current cigarette smoker? Yes / No If yes, how many packs per day? _______ For how long? ______ years

If you are a former smoker, when did you quit? __________ How many packs per day? ____ For how long? _____years

Do you Vape? Yes / No If yes, how often? ________________________ For how long? ________ months/years

Do you drink alcohol? Socially / Daily / Not at all If yes, How much? ________________________________________

Do you use recreational Narcotics? Socially / Daily / Not at all If Yes, What? ____________ For how long? ____years

Have you ever been infected with (circle all that apply) Gonorrhea / Hepatitis / HIV or AIDS / Syphilis / None

Females: Are you pregnant? Yes / No Are you nursing? Yes / No

Do you drive? Yes / No If yes, any visual difficulty while driving? Yes / No If yes, what? _________________________

Do you have prescription glasses? Yes / No If yes, do you wear them? Yes / No Year began wearing? ___________

My glasses are lost/broken? Yes / No Do you wear over-the-counter readers? Yes / No If yes, what strength? _____

Do you currently wear contact lenses? Yes / No Have you ever worn contact lenses? Yes / No

If yes, brand? ______________________ Type? __________________ How often do you change them? ____________

Any problems/concerns with current lenses? Yes / No If yes, please explain: __________________________________

If former contact lens wearer, how long has it been since you wore them? _______________

Why did you stop? __________________________________________________________________________________

Are you currently experiencing any of the following? (Circle all that apply)

Distorted vision Double vision Flashes of light Floaters Halo Burning

Light sensitivity Dryness Mucus discharge Bump on Eyelid Seeing spots
Itching Redness Watery Pain/Soreness Blurred distance vision Loss of vision
Foreign Body Sensation Sandy/Gritty Feeling Color blindness Blurred near vision Glare
Loss of Peripheral Vision Tired eyes Itching Stye Trouble using binoculars

Are you currently being followed by a doctor for an eye condition? Yes / No If yes, please explain?
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 OCULAR AND MEDICAL HISTORY

Have you or anyone in your family ever been diagnosed with the following? (Circle all that apply, and indicate relation to you)

I=Self F=Father M=Mother S=Sister B=Brother MGM=Maternal Grandmother MGF=Maternal Grandfather PGM=Paternal
Grandmother PGF=Paternal Grandfather (Circle appropriate relation)

Cataracts I F M S B MGM MGF PGM PGF

Glaucoma I F M S B MGM MGF PGM PGF
Macular Degeneration I F M S B MGM MGF PGM PGF
Retinal Detachment I F M S B MGM MGF PGM PGF
Retinal Disorders I F M S B MGM MGF PGM PGF
Strabismus (cross-eye) I F M S B MGM MGF PGM PGF
Amblyopia (lazy eye) I F M S B MGM MGF PGM PGF
Drooping Eyelid I F M S B MGM MGF PGM PGF
Blindness I F M S B MGM MGF PGM PGF
Low Vision I F M S B MGM MGF PGM PGF
Head/Eye Injury I F M S B MGM MGF PGM PGF

Allergies I F M S B MGM MGF PGM PGF Emphysema I F M S B MGM MGF PGM PGF
Arthritis Cancer I F M S B MGM MGF PGM PGF Asthma I F M S B MGM MGF PGM PGF
Arteriosclerosis I F M S B MGM MGF PGM PGF Stroke I F M S B MGM MGF PGM PGF
Diabetes I F M S B MGM MGF PGM PGF High Cholesterol I F M S B MGM MGF PGM PGF
Kidney Disease I F M S B MGM MGF PGM PGF Breast Cancer I F M S B MGM MGF PGM PGF
Blood Disorder I F M S B MGM MGF PGM PGF Colon Cancer I F M S B MGM MGF PGM PGF
Heart Disease I F M S B MGM MGF PGM PGF Skin Cancer I F M S B MGM MGF PGM PGF
Migraines I F M S B MGM MGF PGM PGF Prostate Cancer I F M S B MGM MGF PGM PGF
Thyroid Disease I F M S B MGM MGF PGM PGF Kidney Cancer I F M S B MGM MGF PGM PGF
Ulcers I F M S B MGM MGF PGM PGF Other Cancer I F M S B MGM MGF PGM PGF
Reflux I F M S B MGM MGF PGM PGF Lupus I F M S B MGM MGF PGM PGF
Hearing Loss I F M S B MGM MGF PGM PGF Other _______ I F M S B MGM MGF PGM PGF
Anxiety I F M S B MGM MGF PGM PGF Other _______ I F M S B MGM MGF PGM PGF
Depression I F M S B MGM MGF PGM PGF
Alzheimer’s I F M S B MGM MGF PGM PGF
High Blood Pressure I F M S B MGM MGF PGM PGF

Have you ever had eye surgery? Yes / No If yes, please explain: _____________________________________________________
Has anyone else in your family had eye surgery? Yes / No If yes, what and when? _____________________________________
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Have you had any non-eye related surgeries? Yes / No If yes, what and when?
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List all MEDICATIONS you are currently taking:
Medication Dose Directions
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List any Medication ALLERGIES you have:
Medication Reaction
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SIGNATURE OF PATIENT/GUARDIAN DATE