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Heath History Form
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> Health History Form
Health History Form
"
*
" indicates required fields
Exam Date
*
MM slash DD slash YYYY
Name
*
First
Last
Birthdate
*
MM slash DD slash YYYY
Age
*
Email
*
Social Security Number
Only if Medicare or Veteran billing.
Occupation
*
Previous Eye Doctor
Last Eye Exam
MM slash DD slash YYYY
Age of Current Eyeglasses
*
Have you had refractive (cataract/Lasik) surgery?
*
Yes
No
If so, date and type:
*
Do you wear contact lenses?
*
Yes
No
How often do you replace them?
*
Are you having any visual difficulties?
*
Are you currently experiencing any of the following problems with your eyes?
Check all that apply.
Blurred vision
Flashers/Floaters
Redness
Loss of vision
Halos/Glare/Light sensitivity
Excess tearing
Double vision
Dryness
Eye pain or soreness
Tired eyes
Sandy/gritty feeling
Mucus discharge
Burning/itching
Inflammation of the eyelid/styes
Have you been diagnosed with any of the following eye problems?
Check all that apply.
Cataracts
Retinal Detachment/Disease
Crossed Eyes
Lazy Eye/Amblyopia
Dry Eye
Eye Injury
Macular Degeneration
Glaucoma
Other
Please explain your diagnosis and symptoms:
List any medications you are currently taking (including oral contraceptives, aspirin and over the counter medications) *or provide a medication list*
Are you allergic to any medications?
*
Yes
No
Please list
*
List all major surgeries and/or hospitalizations you have had:
*
Primary Care Physician
*
Facility/Location
Last Medical Exam
MM slash DD slash YYYY
Please select any problems you have or have had in the past:
Allergy/Immunologic
Allergy/Hay Fever
Hematologic/Lymphatic
Anemia
Breast Cancer
Bleeding Problems
Cardiovascular/Cardiac
Arteriosclerosis
Heart Disease
High Blood Pressure
Cholesterol
Integumentary (skin)
Cancer
Rashes
Easy Bruising
Constitutional
Weight Loss
Fever
Musculoskeletal
Rheumatoid Arthritis
Joint/Muscle Pain
Ears, Nose, Mouth, Throat
Dry throat/mouth
Sinus Congestion
Neurological
Migraines
Dizziness
Seizures
Stroke
Endocrine
Diabetes
Thyroid Disease
Chronic Fatigue
Psychiatric
Anxiety
Depression
Memory Loss
Hallucinations
Gastrointestinal
Diarrhea/Constipation
IBS/Crohn’s Disease
Ulcers
Reflux
Respiratory
Asthma
Bronchitis
Emphysema
Chronic Cough
Genitourinary
Kidney Disease
Ovarian/Uterine Cancer
Prostate Cancer
If you have a condition that is not listed, please list here:
Are you pregnant or nursing?
Yes
No
Family History
If parents, grandparents, siblings, or children (living or deceased) has any of the following, please indicate which relationship.
Glaucoma
Diabetes
Cataract
Cancer
Macular Degeneration
Heart Disease
Retinal Detachment
High Blood Pressure
Blindness
Kidney Disease
Crossed Eyes
Lupus/Arthritis
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