How is your general health? Circle the response that best describes your state of health.
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- Meagan Peters
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1 Last Name First Name MI Date of Birth / / Home Phone Cell Phone Occupation Emergency Contact Name Contact Phone Number Please complete this form to the best of your ability. Often an approximate answer is the best that can be expected. If you are uncertain, indicate UC. If you are uncomfortable answering a question you may leave it blank, or if you want to talk directly with the doctor about the matter indicate ask me AM. Date of Last Eye Exam / By Who Medical Information: How is your general health? Circle the response that best describes your state of health. Excellent Well Managed and under care Under Care but not under control Under Continuing Care with Frequent Changes in treatments or Medications I don't feel that I'm doing well. Do you take medications or do you need to take special care for any of these body systems? (Please circle NO to confirm your Healthful response.) Gastrointestinal Yes/ No Neurological/ Nervous System Yes/ No Endocrine (Glands) Yes/ No Ears/Nose/Throat Yes/ No Kidney / Urinary Yes/ No Blood / Anemia / Lymph Yes/ No Cardiovascular Yes/ No Muscles/Bones Yes/ No Headaches Yes/ No Allergic/Immunologic Yes/ No
2 Do you take medications or do you need to take special care for any of these body systems? (Please circle NO to confirm your Healthful response.) Eyes Yes/ No Respiratory / Lungs Asthma Yes/ No High blood pressure Yes/ No Integumentary (skin) Yes/ No High Cholesterol or Blood Lipids Yes / No Diabetes Yes/ No Type Date of diagnosis Mental or depressive episodes Yes/ No Please briefly describe. Sensitivities To Medicines or Foods resulting in Gastrointestinal Problems? TO: Medicine Allergies: Yes/ No Skin, Lips, Nose, Sinus, Lungs, Eyes Reaction? Allergy to Your Reactions? Allergy to Reactions? Allergy to Reactions? Allergy to Reactions? Seasonal / Environmental Allergy Yes/ No Skin, Lips, Nose, Sinus, Lungs, Eyes? Allergy to Reactions? Allergy to Reactions? Allergy to Reactions? Other health problems that you want bring to the doctor's attention? Copyright Mendez EyeWear & EyeCareCenters
3 Your Medications Your Vitamins and other Supplements Vitamins Vitamins Vitamins Vitamins Your Surgical Past Have you had any Surgery (operations)? Yes/ No Type/ Kind of Surgery Type/ Kind of Surgery Type/ Kind of Surgery Type/ Kind of Surgery Type/ Kind of Surgery Name of Family Doctor and/or PCP (primary care physician) DO,? or MD? PCP telephone Location Date of last visit Date of Next expected visit
4 Family History High blood pressure Yes/ No Relation (s) Heart Disease Yes/ No Relation (s) High Cholesterol Yes/ No Relation (s) By Pass Surgery Yes/ No Relation (s) Diabetes Yes/ No Relation (s) Retinal detachment Yes/ No Relation (s) Macular degeneration Yes/ No Relation (s) Glaucoma Yes/ No Relation (s) Cataracts Yes/ No Relation (s) Personal and Social History How often What is your most significant healthful physical activity? monthly Tobacco Smoker? Yes / No Packs per Week Do you exercise regularly Yes / No Do You live alone Yes / No Your alcohol consumption more than 2 Daily 2 Daily less than 2 Daily Personal Eye Information Please describe what and when. In the past have you had any Eye Surgery? injuries? illness? Do you wear Contact Lenses? Yes/ No Very Often Often Occasional Seldom Do you wear Eyeglasses? Yes/ No Very Often Often Occasional Seldom For Reading Only For Great Distances Only Most All the Time Your Signature Please Date / / Attending Optometric Physician Date / /
5 It may be time for an Eye Exam. You may be due for your periodic Well Care Examination and have thoughts or concerns directed to your eyeglasses and how they relate to your eyes. We will explore that at your office visit. It is most important that you let us know if you are seeking an evaluation because of a problem involving: Comfort If your reason for the examination is related to the comfort of your eyes such as itching, dryness, burning, stinging, or other painful experience we want to know about that. We also want to know if your eyes appear to you to look not right. For example are they red, puffy or swollen? Are there any lumps, bumps, or freckles on your eyelids that you have notice more.? Eyesight Not including blurriness when reading only or blurriness when looking far away only have you noticed an alteration in your vision that strikes you as not quite right? For example are you sometimes seeing double, that is seeing 2 of something when you know there is only 1 of something. Does your vision seem to change in a short time? Does it seem to come and go? Do you sometimes seem to lose your vision Watery Eyes or a discharge Are you recently wiping stuff from your eyes? Have you been wiping stuff from your eyes for a long time? Previous Recommendation Were you told at your last Examination to keep an eye on something which the doctor had noticed follow up on from time to time and wanted to Please tell us about these findings or symptoms that you noticed. Thank You for beginning your Eye Examination with us. We will see you at your appointment
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