WELCOME TO OUR OFFICE
Patient Health History Name ____________________
Please be certain to answer the following questions completely so that we are able to expedite your exam.
How is your general health? ( Poor ( Fair ( Good ( Excellent
Are you a current smoker? ( Yes ( No
Who is your family physician? _____________________________________ Date of last visit ________________________
Your Vision Information
Are you currently experiencing any of the following with your vision? Please mark yes/no for all items:
Yes No Yes No
Blurred Vision Near ( ( Distorted Vision/Halos ( (
Blurred Vision Distance ( ( Double Vision ( (
Dryness ( ( Tired Eyes ( (
Excess Tears or Watering ( ( Redness ( (
Glare or Light Sensitivity ( ( Loss of Side Vision ( (
Eye Pain or Discomfort ( ( Gritty Feeling ( (
Flashes/Floaters in Vision ( ( Itching ( (
Chronic Infections ( ( Burning ( (
Eye Surgeries ( ( Please list w/dates __________________________________________________
Eye Injuries ( ( Please list w/dates __________________________________________________
Other Eye Conditions ( ( Please list w/dates __________________________________________________
Do you wear glasses ( ( Would you like to update your lenses and/or frame today? ( Yes ( No
Do you wear contacts ( ( If no, are you interested in contact lenses? ( Yes ( No
Personal Medical History
Are you currently experiencing OR have you been diagnosed with any of the following,
Please mark yes or no for all items:
Yes No Yes No
GENERAL RESPIRATORY
Fever ( ( Asthma ( (
Severe Weight Gain/Loss ( ( Chronic Bronchitis ( (
NERVOUS SYSTEM Emphysema ( (
Headaches ( ( ENDOCRINE
Migraines ( ( Diabetes ( (
Seizures ( ( Please circle one: Type I or Type II
Stroke ( ( Thyroid/Other glands ( (
EAR, NOSE, THROAT Elevated Cholesterol ( (
Allergies/Hay Fever ( ( BONES/JOINTS/MUSCLES
Chronic Infections ( ( Rheumatoid Arthritis ( (
Runny Nose ( ( Joint Pain ( (
Chronic Cough ( ( GENITOURINARY
Dry Throat/Mouth ( ( Kidney/Bladder problems ( (
INTEGUMENTARY CARDIOVASCULAR
Skin problems ( ( Heart Pain ( (
GASTROINTESTINAL High Blood Pressure ( (
Diarrhea ( ( Vascular Disease ( (
Constipation ( ( ALLERGIC/IMMUNOLOGIC
LYMPHATIC/HEMATOLOGIC Allergies - General ( (
Anemia ( ( Allergies – Medications ( (
If you answered YES to any of the above or have a condition not listed, please explain. _____________________________
____________________________________________________________________________________________________
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Please list your current medications including eye drops. If you have a list of them and would like us to copy it, please let us know.
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