Medical History Form. Patient Information. Medical History. Middle Initial: Date: Salutation: Sex: First Name: Last Name: Current Address:

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Transcription:

Medical History Form Patient Information Salutation: Sex: Current Address: Email: Employer: First Name: Last Name: Middle Initial: Date: City: Zip Code: Phone 1: Phone 2: Date of Birth: Referral Source: Date of Last Eye Exam: Date of Last Medical Exam: Name of Medical Doctor: Doctors Phone: Medical History Do you have any allergies? Yes No If yes, please explain: Please list any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies): Please list any major injuries, surgeries and/or hospitalizations you have had: Please continue on page 2

Medical History Form Page 2 Medical History Continued Please check any of the following conditions that you have had in the past: Crossed Eyes: Prominent Eyes: Cataracts: Lazy Eye: Glaucoma: Eye Infection: Drooping Eyelid: Retinal Disease: Eye Injury: Do you wear glasses? Yes No If yes, how old is your current pair? Do you wear contact lenses? Yes No If yes, how old is your corrent pair? What type of contact lenses do you wear? Rigid Soft Extended Wear Are they comfortable? Yes No Family History Please check any of the following conditions that you have had in the past and note any family history (parents, grandparents, siblings, children, both living and deceased) for the following conditions: Blindness: Cataracts: Crossed Eyes: Glaucoma: Retinal Disease: Retinal Detachment: Arthritis: Cancer: Diabetes: Heart Disease: Please continue on page 3

Medical History Form Page 3 Family History Continued Please check any of the following conditions that you have had in the past and note any family history (parents, grandparents, siblings, children, both living and deceased) for the following conditions: High Blood Pressure: Kidney Disease: Lupus: Thyroid Disease: Crossed Eyes: If there are any other conditions not listed please explain here: Social History This information is kept strictly confidential. However, you may discuss your condition directly with the doctor if you prefer. I would prefer to discuss my social history information directly with my doctor: Do you drive? Yes No Do you have difficulty driving? Yes No If Yes, please explain: Please continue on page 4

Medical History Form Page 4 Social History Continued Do you use tobacco products? Yes No If Yes, what type and how long? Do you use drink alcohol? Yes No If Yes, what type and how long? Do you use illegal drugs? Yes No If Yes, what type and how long? Have you ever been exposed to or infected with Gonorrhea, Hepatitis, HIV, or Syphilis? Yes No If Yes, please explain: Please continue on page 5

Medical History Form Page 5 Review of Systems Please check only those that apply if you currently, or have ever had any problems in the following areas: Constitutional Fever, Weight Loss/Gain: Integumentary Skin: Neurological Headaches: Migraines: Seizures: Ears, Nose, Throat, Mouth Allergies/Hay Fever: Sinus Congestion: Runny Nose: Post-Nasal Drip: Chronic Cough: Dry Mouth: Endocrine Thyroid/Other Glands: Respiratory Asthma: Chronic Bronchitis: Emphysema: Eyes Loss of Vision: Blurred Vision: Distorted Vision/Halos: Loss of Side Vision: Dryness: Mucous Discharge: Redness: Sandy or Gritty Feeling: Itching: Burning: Foreign Body Sensation: Excess Tearing/Watering: Glare/Light Sensitivity: Eye Pain/Soreness: Chronic Infection of Eye or Lid: Sties or Chalazion: Flashes/Floaters in Vision: Tired Eyes: Please continue on page 6

Medical History Form Page 6 Review of Systems Continued Please check only those that apply if you currently, or have ever had any problems in the following areas: Vascular/Cardiovascular Diabetes: Heart Pain: High Blood Pressure: Vascular Disease: Gastrointestinal Diarrhea: Constipation: Genitourinary Genitals/Kidney/Bladder: Bones/Joints/Muscles Rheumatoid Arthritis: Muscle Pain: Joint Pain: Lymphatic/Hematologic Anemia: Bleeding Problems: Other Allergic/Immunologic: Psychiatric: If you selected any of the above or have a condition not listed please explain here: End of Medical History Form. Please bring the completed form with you to your appointment at Grove Eye Care.

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