Welcome to Our Office

Welcome To Our Office

Medical History Record

Name: ______Birth Date: ____/____/____ Age: ____ First MI Last Email______Phone: ______Employer: ______Occupation: ______

Family Doctor: ______Pharmacy: ______

Date of last physical: ______Height: ______Weight: ______

Referring Doctor: ______Phone: ______

Do you currently wear glasses? □ Yes □ No ___ Prog ___Bif ___Trif ___SV ___Readers Do you currently wear contacts? □ Yes □ No ___Disp ___SV ___Multif ___GP ___Monovison

What is the purpose of your visit today? No Vision Issues  Problem  if so please explain: ______

Are you currently having any Headaches __Y__N, Flashes __Y__N, Floaters __Y__N, Redeye __Y __N, Abrasions __Y__N, Allergy __Y __N, Foreign Body __Y __N, Lumps/Lesions __Y __N, Pain __Y __N

Ask them to bring their list of medications with Dosage and how they are taken.

List all medications, dosage & reason for taking: (Prescription and Over-the-Counter) Attach list if necessary.

(Name & Dosage) (Reason (Name & Dosage) (Reason for Medications for taking) Occular Meds taking)

(1) (1) (2) (2) (3) (3) (4) (4) (5) (5) (6) (6)

Do you have allergies to any medications? Yes  NO  If YES, List medications and reactions: ______

Are you a Diabetic? Y __ N__ Type ____ 1 or ___2 What is your A1C ______Review of Systems Do you presently have any problems in the following areas?

Allergic/Immunologic YES NO Gastrointestinal YES NO Integumentary YES NO Respiratory YES NO Seasonal allergies   (Stomach/Intestines) (Skin and/or Breast) (Lungs/ Breathing) Immune problems   Jaundice/Hepatitis   Psoriasis   Asthma   Ulcers/Bleeding   General allergies   Acne Rosacea   Emphysema   Hiatus Hernia   Lupus   Tuberculosis   Other______IBS   Other______Lung Cancer   Acid Reflux   Cancer______Sarcoidosis   Other______COPD   Cancer______Cystic Fibrosis   Other______Cardiovascular YES NO Genitourinary YES NO Musculo-Skeletal YES NO Congestive heart failure   (Genitals/Kidney/Bladder) Degenerative arthritis  Heart murmur   Kidney disease   Rheumatoid arthritis   Heart attacks   Kidney Stones   Muscle/ Joint pain   Heart Palpations   Other______Fibromyalgia   Blood pressure   Cancer______Scoliosis   Chest pain/angina   Osteoporosis   Other______Other______

Constitutional Symptoms Head YES NO Neurological YES NO (Ear, Nose, Mouth, Throat) Migraines   YES NO Hearing problems   Seizures   Fever   Sinus congestion   Stroke/Paralysis   Weight Loss   Headaches   Vertigo   Fainting   Chronic cough   Bell’s Palsy   Dizziness   Dry throat/mouth   Epilepsy   Disorientation   Other______Multiple Sclerosis   Other______Muscular Dystrophy  Neurofibromatosis   Other______

Endocrine YES NO Hematologic/Lymphatic Psychiatric YES NO Diabetes   Y Depression   How Long?______ES NO Schizophrenia   Today’s Reading______Anemia   Bipolar   Pancreatic Cancer   Sickle Cell disease   ADD   Crohn’s Disease   Leukemia   Alzheimer’s   Thyroid Disorder   Other______Anxiety Disorder   Hormone Replacement   Cancer______Autism   Elevated Cholesterol   Dementia   Hyperthyroidism   Other______Other______Cancer______Past History List any major illneses and injuries you have had in the past: ______List any significant eye history (i.e.: cataracts, macular degeneration, glaucoma, injuries to eyes) you have had: ______List any surgeries you have had in the past including approximate date of surgery: ______

Family History (M=mother, F=father, B= brother, S= sister, MGP or PGP=grandparent)

Patient Family If Family, what relation to you Patient Family If Family, what relation to you   Glaucoma______  Hepatitis______  Lazy Eye______  HIV +/ AIDS______  Diabetes ______  Neurofibromatosis______  High Blood Pressure______  Keratoconus______  Heart Disease______  Lyme disease______  Sarcoidosis______  Graves Disease/Thyroid______  Asthma/ Breathing Problems______  Myasthenia Gavis______  Migraine Headaches______  Retinal Detachment______  Lupus______  Multiple Sclerosis______  Cataracts______  Blindness______  Cataract Surgery______  Retinitis Pigmentosa______  Corneal Dystrophies______  Macular Degeneration______

Social History Do you smoke? □ Yes □ No If YES, How many packs a day? ______Did you quit? □ Yes □ No How long ago? ______Do you drink alcohol? □ Yes □ No If YES, How many drinks a day/ week? ______Do you use narcotics drugs? □Yes □No Have you ever had a sexually transmitted disease? □ Yes □ No Have you ever had a blood transfusion? □ Yes □ No