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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