Patient History Form

Patient History Form

History of present illness

Vision complaint
Are you experiencing blurred vision?
Check all that apply
Areas affected
Symptoms
Are you experiencing vision loss?
Impairs
Symptoms
VISUAL SYMPTOMS (are you experiencing any of the following symptoms?)
OCULAR SYMPTOMS (are you experiencing any of the following symptoms?)

Patient History

OCULAR HISTORY (Check all that apply)
Pregnant?
Nursing?

Family Medical History

(Please indicate any family members: mother, father, maternal/paternal grandparents, brother or sister) who were diagnosed with any of the following:

Ocular Family History

(Please indicate any family members: mother, father, maternal/paternal grandparents, brother or sister) who were diagnosed with any of the following:

Social History

Tobacco use
Smoke or smokeless?
Narcotic use?
Alcohol use?
Sexually Transmitted Disease
HIV Positive
Blood Transfusion
Developmental History
Do you currently wear glasses?
Do you wear contacts?
With contacts on, are you happy with comfort and vision?
With contacts on, any dryness?
Are you interested in contact lenses?
Do you use low vision devices?

Review of Symptoms

Allergy
Cardivascular
Constitutional
Endocrine
Gastrointestinal
Genitourinary
Ears, Nose, Throat
Hematologic / Lymphatic
Immunologic
Integumentary / Skin
Musculoskeletal
Neurologic
Psychiatric
Respiratory

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