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Patient Medical History

Please fill this form out, or download our printable forms here

Social History

Full Name *

Current Occupation *

Previous Occupation *

Do you drive? *

Do you have visual difficulty when driving? *

Do you have problems with night vision? *

Do you Drink Alcohol? *

How often do you drink alcohol? *

Do you Smoke? *

how many cigarettes/pack(s) a day? *

Do you currently wear glasses/contacts? *

How long have you had the current prescription? *

List all major illnesses and injuries

List non-eye based surgeries

List eye surgeries

Detailed Eye History

Loss Of Vision

Explanation Of Problem (Loss Of Vision) *

Blurred Vision

Explanation Of Problem (Blurred Vision) *

Distorted Vision (HALOS)

Explanation Of Problem (Distorted Vision (HALOS)) *

Double Vision

Explanation Of Problem (Double Vision) *

Dryness

Explanation Of Problem (Dryness) *

Mucous Discharge

Explanation Of Problem (Mucous Discharge) *

Redness

Explanation Of Problem (Redness) *

Sandy or gritty feeling

Explanation Of Problem (Sandy or gritty feeling) *

Itching

Explanation Of Problem (Itching) *

Burning

Explanation Of Problem (Burning) *

Tearing/ Watering

Explanation Of Problem (Tearing/ Watering) *

Glare/Light Sensations

Explanation Of Problem (Glare/Light sensations) *

Eye Pain Or Soreness

Explanation Of Problem (Eye Pain Or Soreness) *

Styes, Chalazions

Explanation Of Problem (Styes, Chalazions) *

If you have any issues in the areas of your body listed below, please check the box next to it.

Current Issues

Sinus congestionRunny noseChronic CoughChronic BronchitisCardiovascular (Heart/Blood Vessel)Gastrointestinal (Stomach/Intestines)Genitourinary (Genitals/Kidneys/Bladder)Muscle ProblemsArthritis ProblemsIntegumentary (Skin and/or Breast)Neurological ProblemsPsychiatric ProblemsEndocrine ProblemsBlood ProblemsLymph Node ProblemsSwelling ProblemsHead Allergy SymptomsSeasonal AllergiesInflamatory Conditions

Please specify your respiratory issues (Ear, Nose, Mouth, Throat, Lungs) *

Please specify your Cardiovascular (Heart/Blood Vessel) issues *

Please specify your gastrointestinal issues (Stomach/Intestines) *

Please specify your Genitourinary (Genitals/Kidneys/Bladder) issues *

Please specify your Musculoskeletal issues (Muscles problems, arthritis problems) *

Please specify your Integumentary (Skin and/or Breast) issues *

Please specify your Neurological issues *

Please specify your Psychiatric issues *

Please specify your Endocrine issues *

Please specify your Hematologic / Lymphatic issues (Blood, Lymph Nodes, Swelling) *

Please specify your Allergic / Immunologic issues (Allergies, Inflammatory Conditions) *

If any of the below issues run in your family, please check the box:

Family History

BlindnessCataractGlaucomaMacular DegenerationRetinal DetachmentArthritisCancerDiabetesHeart AttacksHigh Blood PressureKidney DiseaseLupusDry eye problemsStrokeThyroid DiseaseLymph Node ProblemsTuberculosisOther Diseases

Which family members have a history of Blindness? *

Which family members have a history of Cataracts? *

Which family members have a history of Glaucoma? *

Which family members have a history of Macular Degeneration? *

Which family member(s) have a history of Retinal Detachment? *

Which family member(s) have a history of Arthritis? *

Which family member(s) have a history of Cancer? *

Which family member(s) have a history of Diabetes? *

Which family member(s) have a history of Heart Attacks? *

Which family member(s) have a history of High Blood Pressure? *

Which family member(s) have a history of Kidney Disease? *

Which family member(s) have a history of Lupus? *

Which family member(s) have a history of Dry eye problems? *

Which family member(s) have a history of Stroke? *

Which family member(s) have a history of Thyroid Disease? *

Which family member(s) have a history of Lymph Node Problems *

Which family member(s) have a history of Tuberculosis? *

What other diseases are in your family history? *

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