Thank you for trusting us with your eye health care. We promise to do our best to provide you with the finest care available. If you have any questions, please do not hesitate to call us. MEDICAL HISTORY FORM Birthdate Patient Name Gender: Male / Female Today’s Date Primary Care Physician Current eye problem/symptoms? NONE / Routine Eye Exam Currently wear contacts? Yes / No Details Injury Related? If Yes, How did it occur? PAST MEDICAL HISTORY (Please circle all that apply or have applied for you) NONE Anxiety Coronary Artery Disease Hypothyroidism Arthritis Depression Leukemia Artificial joints Diabetes Lung Cancer Atrial Fibrillation End Stage Renal Disease Lymphoma Asthma GERD Pacemaker / Defibrillator Yes / No BPH Hearing Loss Prostate Cancer Bone Marrow Transplantation Hepatitis Radiation Treatment Breast Cancer Hypertension Seizures Colon Cancer HIV / AIDS Stroke COPD High Cholesterol Valve Replacement Other PAST SURGICAL HISTORY (Please list all Surgical Procedures / Hospitalizations and Year) NONE Year Year Year Year MEDICATIONS ALLERGIES (Please list all Allergies) NONE (Please list all current prescription & supplements) NONE PLEASE COMPLETE BOTH SIDES OF THIS FORM. THANK YOU OCULAR (EYE) HISTORY(Please list eye conditions and when treated) NONE Year Year Year OCULAR (EYE) SURGERY (Please list all eye surgical procedures and when) NONE Year Year Year FAMILY HISTORY (Please circle all that apply and indicate relation) NONE Relation Relation Relation Cataracts Blindness Migraine Diabetes Cancer Retinal Detachment Glaucoma CVA Strabismus Macular Degeneration (AMD) Heart Disease Other SOCIAL HISTORY (Please check all that apply) CIGARETTE SmOKIng: ALCOHOL USE: ILLICIT DRug USE: SAFETY: Never Smoked Alcohol: None None I feel safe at home Quit: Former Smoker Alcohol: < 1 drink / day Drug use I do not feel safe at home Smokes less than daily Alcohol: 1-2 drinks / day IV Drug use Smokes daily Alcohol: 3 or more drinks / day Other PEDIATRIC HISTORY (Complete only if child patient) Gestational Age at Birth: weeks Maternal illness during pregnancy: Birth Weight: lbs oz REVIEW OF SYSTEMS (Please circle all that apply) EYES/VISION CARDIOVASCULAR INTEgumENTARY Poor Vision High Blood Pressure Rash Eye Pain Rapid Heart Beat Changing Moles Tearing Redness RESPIRATORY NEUROLOGICAL Jaw Pain Congestion Headache Scalp Tenderness Wheezing Seizure Amaurosis Fugax Shortness of Breath Stroke Loss of vision Paralysis GASTROINTESTINAL G.I. EnDOCRINE Upset Stomach PSYCHIATRIC Diabetes Diarrhea Anxiety Hyperthyroid Constipation Depression Hypothyroid Burning on Urination Insomnia Urinary Frequency CONSTITUTION / SYSTEM Incontinence HEMATOLOGIC/LYmphATIC Fever Bleeding Chills MUSCULOSKELETAL Anemia Weight Loss Joint Pain Stiffness ALLERGIC/ImmunOLOGIC ENT AND MOUTH Arthritis Allergies Stuffy Nose Hay Fever Ear Ache Hives Cough Dry Mouth PLEASE COMPLETE BOTH SIDES OF THIS FORM. THANK YOU .