Confidential Medical History


Patient’s Name:                                          

Eye Health:

Have you ever had any eye problems with:

Problem with Eyesight Yes No
Eye Pain / Discomfort  Yes No
Redness  Yes No
Dry / Burning Eyes Yes No
Itching Eyes Yes No
Double Vision Yes No
Lazy Eye / Eye Turning Yes No
Pressure in or Behind Eyes Yes No
Flashes of Light   Yes No
Floaters / Spots    Yes No
Cataracts     Yes No
Glaucoma Yes No
Macular Degeneration Yes No
Eye Injury  Yes No
Other:                                        Yes No

Past Medical History:

Have you ever had any problems

in any of the following areas:

Diabetes      Yes No
High Blood Pressure Yes No
Heart Problems Yes No
Breathing Problems   Yes No
Pacemaker  Yes No
Hay Fever / Allergies Yes No
Headaches Yes No
Fainting Spells / Dizziness Yes No
Stroke      Yes No
Arthritis  Yes No
Thyroid  Yes No
Cholesterol  Yes No
Cancer  Yes No
AIDS/HIV or Hepatitis  Yes No
Do you smoke? Yes No
Do you drink alcohol?    Yes No
Are you pregnant?  Yes No
Allergy to medicines? Yes No

If Yes, Please List:                                                    
                                                                

 
Physician’s Name:                                       

Review of Body Systems:
Have you ever had any problemsin any of the following areas:
Lungs    Yes No
Heart / Blood  Yes No
Skin       Yes No
Head / Neck / Neurologic  Yes No
Psychiatric    Yes No
Ears / Nose / Throat   Yes No
Stomach or Digestion   Yes No
Kidney or Bladder  Yes No
Bones / Muscles / Joints   Yes No


Please List Any Other Serious Illness:
                                                                    
                                                                    
                                                                    


Please List Any Previous Surgery:                                                                     
                                                                    
                                                                    
                                                                    

Please List All Current Medications / Eyedrops:                                                                       
                                                                    
                                                                    
                                                                    
                                                                    
                                                                    
                                                                    

Family History:

Have any blood relatives had problems in any of the following areas?

Diabetes   Yes No
Heart / Blood Pressure Yes No
Glaucoma      Yes No
Macular Degeneration Yes No