BRIGHTON EYE CARE
BRIGHTON EYE CARE
Patient’s Name: __________________________________________ DOB: _____________Today’s Date: _____________ Mailing Address: ____________________________________________________________________________________ SSN: _______________________ Occupation: ____________________________________________________________ Home Phone: ______________________ Work Phone: _______________________ Cell Phone: ____________________ Text Messaging Y/N Email Address: _________________________________________________________________ Have you ever fainted? Y/N If yes, circumstances? ________________________________________________________
|Patient’s Eye History: |Patient’s Medical History: |
|Circle all that apply. |Circle all that you have been diagnosed with. |
| | |
|Serious eye injuries ______________________ |Cardiovascular: Integumentary: Blood /|
| |Lymph: |
|Eye surgeries___________________________ |High Cholesterol Eczema |
| |Bleeding disorder |
|Red eyes / infections |Heart Attack Melanoma |
| |History of blood loss |
|Iritis |High / low blood pressure Rosacea |
| |Reynaud’s |
|Crossed / lazy eye / patching therapy |Anemia |
|_______________________________________ |Respiratory: Gastrointestinal: |
| | |
|First Glasses Age: _____ |Asthma Crohn’s Disease |
| |Allergic / Immunologic: |
|First Contact Lenses Age: ______ |Sleep apnea Ulcers |
| |Seasonal allergies |
| |COPD |
|Will you be needing new: |Lupus |
| | |
| |Psychiatric: Ear, Nose, & Throat: |
|Glasses Sunglasses Contacts |Endocrine: |
| |Depression Hearing Loss |
| |Diabetes |
| |Anxiety Dry Mouth |
| |Thyroid disorder |
| | |
| |Neurological: Musculoskeletal: |
| |Other: |
| |Stroke Arthritis |
| |Cancer |
| |Parkinson’s Fibromyalgia |
| | |
| |Multiple Sclerosis Rheumatoid Arthritis |
| |Migraine |
| | |
| |Bell’s Palsy Surgeries: |
| | |
|Patient’s Social History: | |
|Tobacco Use: |Alcohol Use: |
|Never / Quit smoking _________ ago / Currently _____pack(s) a day |Never / Socially / 1-2 drinks/day / Above average / Alcohol dependent |
| | |
|Marital Status: | |
|Single / Married / Partnered / Divorced / Widowed |Do you drive? Yes / No |
Current Medications: _______________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________
|Family Eye History: Parents, grandparents, siblings, child |Family Medical History: Parents, grandparents, siblings, child |
|Circle all that apply |Circle all that apply |
|□ Unknown |□ Unknown |
|□ Adopted |□ Adopted |
| | |
|Macular Degeneration Eye Turn / Lazy Eye |Cancer |
|Cataracts (younger than age 45) Blindness |Migraines |
|Retinal Detachment Glaucoma |Heart Attack Diabetes |
| |Stroke Thyroid|
|Other: ____________________________________________________ |Disorder |
|NONE |High Blood Pressure |
| |Other: ____________________________________________________ |
| |NONE |
Patient Signature: ______________________________________________________ Date: _________________
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