Jensen Eyecare Center - Optometrist in Iowa City, IA
MEDICAL HISTORY AND MEDICATIONSName:__________________________________________________________________Date:_______________________When was your last eye exam?_________________ Where?__________________________________________________________Who is your primary care physician?_____________________________________________ When was last visit?_______________Please list any major surgeries/hospitalizations: _______________________________________________________________________________________________________________________________________________________________________________Please list medication allergies:__________________________________________________________________________________Please list all the medications you are taking – including the dosage (ok to attach medication list):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are you having any problems with your present glasses or contacts?____________________________________________________________________________________________________________Are you interested in contact lenses? ? yes ? no Do you suffer from dry eye? ? yes ? noDo you have any other hobby, recreational or occupational visual needs? ________________________________________________Current General Health Conditions:FeverWeight loss/gainHigh Blood PressureStrokeHigh Cholesterol Ears/Nose/ThroatSinus ProblemsAsthmaRespiratory ProblemsGastrointestinalKidneyHIV/AIDSArthritisMuscle/Bone/Joint? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? noSkinThyroidMigraineSeizuresMultiple SclerosisAnxiety/DepressionPsychiatricDiabetes Type 1Diabetes Type 2Bleeding ProblemsAllergiesDry MouthCancer _________________Pregnant or Nursing? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? no? yes ? noOther:___________________________________________________________________________________________________Ocular History:GlaucomaCataractsMacular DegenerationEye InjuryRetinal DiseaseBlindness? yes ? no ? yes ? no? yes ? no ? yes ? no ? yes ? no? yes ? no Strabismus (eye turn)Amblyopia (lazy eye)Diabetic RetinopathyDry EyesGlasses/Contact Lens Correction? yes ? no ? yes ? no ? yes ? no ? yes ? no ? yes ? noOther:__________________________________________________________________________________________________Family History:AmblyopiaBlindnessCataractMacular DegenerationRetinal DisorderStrabismus (eye turn)? yes ? no ? yes ? no ? yes ? no ? yes ? no ? yes ? no ? yes ? noArthritisCancer DiabetesThyroid DiseaseHigh Cholesterol High Blood Pressure? yes ? no ? yes ? no ? yes ? no ? yes ? no ? yes ? no ? yes ? noIf “yes,” list the relative with the condition: ________________________________________________________________________________ ................
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