InVision EyeCare Medical History



InVision EyeCare Medical History

Patient Name:__________________________ Age:_______ Sex: Male / Female Date:_____________

Allergies:__________________________________________________________________________________

History of the following diseases: (Please indicate with a check ( if present)

Self / Family Self / Family

General/Constitutional Respiratory

Cancer ____ / ____ Asthma ____ / ____

Significant weight loss/gain ____ / ____ COPD ____ / ____

Emphysema ____ / ____

Skin/Integumentary Sleep Apnea ____ / ____

Rash ____ / ____ Other_______ ____ / ____

Melanoma ____ / ____

Eczema ____ / ____ Cardiovascular/Vascular

Psoriasis ____ / ____ Diabetes ____ / ____

Rosacea ____ / ____ High blood pressure ____ / ____

Shingles ____ / ____ High cholesterol ____ / ____

Other________ ____ / ____ Stroke ____ / ____

TIA ____ / ____

Neurological Heart disease ____ / ____

Chronic headache ____ / ____ Irregular heart beat ____ / ____

Migraines ____ / ____ Chest pain ____ / ____

Epilepsy/seizures ____ / ____ Dizziness ____ / ____

Multiple Sclerosis ____ / ____

Tingling/numbness ____ / ____ Immunologic

Lupus ____ / ____

Endocrine Tuberculosis ____ / ____

High thyroid ____ / ____ HIV/AIDS ____ / ____

Low thyroid ____ / ____ Hepatitis ____ / ____

Hormonal imbalance ____ / ____ Liver disease ____ / ____

Sarcoidosis ____ / ____

Lymphatic/Blood Disorders

Anemia ____ / ____ Genitourinary

Bleeding tendency (hemophilia) ____ / ____ Kidney disease ____ / ____

Increased blood clotting ____ / ____ Prostate disease ____ / ____

Sickle Cell ____ / ____ Ovarian disease ____ / ____

Leukemia ____ / ____ Sexually transmitted disease ____ / ____

Ears/Nose/Mouth/Throat Bones/Joints/Muscles

Hearing Loss ____ / ____ Rheumatoid Arthritis ____ / ____

Chronic allergies ____ / ____ Chronic joint/muscle pain ____ / ____

Sinus congestion ____ / ____ Fibromyalgia ____ / ____

Chronic cough ____ / ____ Osteoporosis ____ / ____

Recurrent cold sores ____ / ____

Psychiatric

Gastrointestinal Depression ____ / ____

Ulcers ____ / ____ Anxiety ____ / ____

Colitis ____ / ____ Attention deficit disorder ____ / ____

Irritable bowel syndrome ____ / ____ Bipolar disorder ____ / ____

Crohn’s Disease ____ / ____ Schizophrenia ____ / ____

Previous surgeries:__________________________________________________________________________

Tobacco use: Yes / No Alcohol use: Yes / No Drug/Substance abuse: Yes / No

~Continued on back~

Current Medications:________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

If you are female, possibility of pregnancy? Yes / No

Ocular History

History of eye diseases: (Please indicate with a check ( if present)

Self / Family

Glaucoma ____ / ____

Cataracts ____ / ____

Macular Degeneration ____ / ____

Retinal Detachment ____ / ____

Blindness ____ / ____

Retinal Disease ____ / ____

Color Blindness ____ / ____

Strabismus (eye turn) ____ / ____

Amblyopia (“Lazy” eye) ____ / ____

Other_______________ ____ / ____

Do you suffer from any of the following:

Blurry Vision ________ Sinus Problems ________ Flashes of Light _______

Dry Eyes ________ Headaches ________ Halos _______

Watery Eyes ________ Pain in your eyes ________ Floaters _______

Seasonal allergy ________ Dizziness ________ Other _______

Have you ever had any serious trauma to your eyes? Yes / No ________________________________

Have you ever had any serious eye infections? Yes / No ____________________________________

Do you use any prescription or non-prescription eye drops? Yes / No __________________________

Contact Lens History

Contact Lens use? Yes / No What kind? Soft / Hard Brand:_______________________

Current replacement schedule? __________________ Brand of cleaning solution: ____________

Do you ever sleep in your contact lenses? Yes / No (If Yes, how often?_______________________)

Approximate date of last eye exam:_______________ Present eye doctor:__________________________

Approximate date of last physical exam:___________ Present medical doctor:_______________________

Purpose of today’s visit:______________________________________________________________________

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