Patient History Form Patient History Form Patient Name * Date of Birth * Date of Service * Reason for Visit * Chief Complaint * History of present illness Vision complaint With glasses With contacts With glasses/contacts Are you experiencing blurred vision? Yes No Check all that apply Right eye Left eye Sudden Gradual Since childhood Areas affected All ranges Distance Close range Computer range Symptoms Squinting Headache Eye strain Words run together Loss of place reading Are you experiencing vision loss? Yes No When do the symptoms begin and how do they occur? Impairs TV Computer Driving School Performance Symptoms Dim Hazy Cloudy Distorted VISUAL SYMPTOMS (are you experiencing any of the following symptoms?) Right eye Left eye Headaches Loss of place reading Misreads words Letter reversals Light sensitivity Glare Halos Double vision Poor night vision When do the symptoms begin and how often do they occur? OCULAR SYMPTOMS (are you experiencing any of the following symptoms?) Right eye Left eye Pain Soreness Foreign body sensations Dry sandy feeling Redness Burning Itching Watery eyes Light sensitive Mucus discharge When do the symptoms begin and how often do they occur? Patient History OCULAR HISTORY (Check all that apply) Right eye Left eye Both eyes Cataracts Glaucoma Macular Degeneration Retinal Detachment Amblyopic (lazy eye) When were you diagnosed with the above? Eye injury or other? Medical History Pregnant? Yes No Nursing? Yes No Systemic Surgeries? Medications (please list ALL medications, prescription and over the counter with the dosages Allergies (please list any allergies including medication, non-medication, or seasonal) Family Medical History (Please indicate any family members: mother, father, maternal/paternal grandparents, brother or sister) who were diagnosed with any of the following: Hypertension Diabetes Heart disease Elevated Cholesterol Cancer, what kind Other Ocular surgeries Ocular Family History (Please indicate any family members: mother, father, maternal/paternal grandparents, brother or sister) who were diagnosed with any of the following: Macular Degneration Cataracts Glaucoma Keratoconus Other Social History Tobacco use Never used Currently use Former user If former user, when did you quit? Smoke or smokeless? Smoke Smokeless Narcotic use? None Recreational Dependent Alcohol use? None Socially 1-2 a day 3 or more daily Sexually Transmitted Disease Yes No HIV Positive Yes No Unknown Blood Transfusion Yes No Developmental History Full-term or premature Learning Development or speech delays Do you currently wear glasses? Full-time Part-time Never Do you wear contacts? Yes No With contacts on, are you happy with comfort and vision? Yes No With contacts on, any dryness? Yes No Are you interested in contact lenses? Yes No Do you use low vision devices? Yes No Review of Symptoms Allergy Hay Fever Dust Mold Animal Dander Other Cardivascular Heart Pain High Blood Pressure Vascular Diseases Other Constitutional Fever Weight Loss Other Endocrine Diabetes A1C Thyroid Other Year diagnosed with diabetes? Year diagnosed with A1C? Gastrointestinal IBS Diarrhea Constipation Ulcers Other Genitourinary Kidney Bladder Genitals Other Ears, Nose, Throat Sinusitis Chronic Cough Ear Infection Dry Throat/mouth Other Hematologic / Lymphatic Anemia Bleeding Disorder Swelling Other Immunologic Sjogren's Syndrome Shingles, Herpes, Zoster Other Integumentary / Skin Rashes Brest Other Musculoskeletal Arthritis Rhueumatoid Arthritis Muscle Pain Joint Pain Other Neurologic Headaches Migranes Seizures Other Psychiatric Depression Compulsive Disorder Nervous Disorder Other Respiratory Asthma Sleep Apnea Emphysema Lung Cancer Shortness of Breath Other If you are human, leave this field blank. Submit
