Name

First Last

Date

Date of Birth

When was your last eye Exam?

Do you wear glasses?

Yes
No

If you wear glasses, what do you use them for?

Do you wear contact lenses?

Yes
No

If you wear contact lenses how many days a week? What Brand?

Please list any prescription or non prescription medications you are taking

Please list any prescription or non prescription eye drops you are using

YOUR OCULAR HISTORY

Please give details on any YES answer.

History of Eye Injury.

Yes
No

explain

History of Eye Infection

Yes
No

explain

History of Eye Disease

Yes
No

explain

History of Eye Turn

Yes
No

explain

History of Eye Surgery

Yes
No

explain

History of Eye Surgery (Give dates if possible)

Do you have a family history of Macular Degeneration? If Yes who in the family?

Do you have a family history of Glaucoma? If Yes who in the family?

Do you smoke? If Yes how many packs per day?

Do you drink alcohol?

Do you have any communicable disease?

If female, are you pregnant or nursing?

Yes pregnant
Yes nursing
Yes both
No

Due Date if pregnant

PERSONAL MEDICAL HISTORY

Please check whether there is a history of problems in each category.

Cancer

Yes
No

Allergies (Seasonal / Year round / Medications)

Yes
No

Cardiovascular C High Blood Pressure / Heart Disease / Circulation Problem / Stroke)

Yes
No

Constitutional difficulties (general feeling of wellness)

Yes
No

Diabetes (Yr Diagnosed)/ Increased Cholesterol/Gout/Low Thyroid/Hyperthyroid

Yes
No

Gastrointestinal/Stomach

Yes
No

Genitourinary

Yes
No

Head (Ear/Nose/Throat Disorder/Headaches/Migraines/Sinus Problems)

Yes
No

Blood Disease/Lymphatic

Yes
No

Immunologic

Yes
No

Skin

Yes
No

Musculoskeletal/Arthritis

Yes
No

Neurological

Yes
No

Psychiatric/Depression

Yes
No

Respiratory

Yes
No

Other

Yes
No

Medical History

Medical History

YOUR OCULAR HISTORY

PERSONAL MEDICAL HISTORY

Allisonville Eye Care Center