"Patient Medical History Form"

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PATIENT MEDICAL HISTORY FORM
Name of Family Physician:____________________________Date of Last Physical:________________________
CURRENT MEDICATIONS (
Rx or over the counter, list name of medications including eye drops, vitamins & birth control pills)
______________________________________________________________________________________________
ALLERGIES TO MEDICATIONS?
Yes
No If yes, which: _______________________________________
List all major illnesses (glaucoma, diabetes, high cholesterol, high blood pressure, etc) or injuries (concussion, etc):
_______________________________________________________________________________________________
List any surgeries you have had (cataract, appendectomy, etc.)__________________ __________________________
Do you smoke?
___yes _____no
if Yes, how much?___________ How many years?_________________
Do you drink alcohol? ____yes ____no
if Yes, how much?_________________________________________
REVIEW OF SYSTEMS
Do you currently have any problems in the following areas? If YES, please provide details.
Details (
condition, date of diagnosis, and treatment)
YES
NO
EYES(distance blur, near blur, eye pain, tearing,
redness, dry eyes, etc)
GENERAL / CONSTITUTIONAL (fever, heat
stroke, weight loss, weight gain, unusually tired)
EARS, NOSE, THROAT (hard of hearing,
stuffy nose, earache, cough, dry mouth, etc.)
CARDIOVASCULAR (high blood pressure,
racing pulse, etc)
GASTROINTESTINAL (stomach upset,
diarrhea, constipation, hernia, ulcers, etc.)
FEMALES Are you pregnant? Nursing?
MUSCLES, BONES, JOINTS (joint pain,
stiffness, swelling, cramps, arthritis, etc.)
SKIN (pimples, warts, growths, rash, etc.)
NEUROLOGICAL (numbness, headache,
seizures, etc.)
PSYCHIATRIC (anxiety, depression, insomnia)
ENDOCRINE (diabetes, hypothyroid, etc.)
BLOOD / LYMPH (bleeding, high cholesterol,
anemia, sicle cell, blood transfusions, etc.)
ALLERGIC / IMMUNOLOGIC (sneezing,
swelling, redness, itching, hives, lupus, etc.)
CANCER (please list type)
OTHER
FAMILY HISTORY
Please note any family history (parents, grandparents, siblings: living or deceased) for the following conditions:
DISEASE/CONDITION
YES
NO
RELATIONSHIP TO YOU
Glaucoma
Macular Degeneration
Cataract
Retinal Detachment/Disease
Diabetes
High Blood Pressure
Crossed Eyes/ Lazy Eyes
Blindness
Cancer
Heart Disease
Lupus
Thyroid Disease
PATIENT MEDICAL HISTORY FORM
Name of Family Physician:____________________________Date of Last Physical:________________________
CURRENT MEDICATIONS (
Rx or over the counter, list name of medications including eye drops, vitamins & birth control pills)
______________________________________________________________________________________________
ALLERGIES TO MEDICATIONS?
Yes
No If yes, which: _______________________________________
List all major illnesses (glaucoma, diabetes, high cholesterol, high blood pressure, etc) or injuries (concussion, etc):
_______________________________________________________________________________________________
List any surgeries you have had (cataract, appendectomy, etc.)__________________ __________________________
Do you smoke?
___yes _____no
if Yes, how much?___________ How many years?_________________
Do you drink alcohol? ____yes ____no
if Yes, how much?_________________________________________
REVIEW OF SYSTEMS
Do you currently have any problems in the following areas? If YES, please provide details.
Details (
condition, date of diagnosis, and treatment)
YES
NO
EYES(distance blur, near blur, eye pain, tearing,
redness, dry eyes, etc)
GENERAL / CONSTITUTIONAL (fever, heat
stroke, weight loss, weight gain, unusually tired)
EARS, NOSE, THROAT (hard of hearing,
stuffy nose, earache, cough, dry mouth, etc.)
CARDIOVASCULAR (high blood pressure,
racing pulse, etc)
GASTROINTESTINAL (stomach upset,
diarrhea, constipation, hernia, ulcers, etc.)
FEMALES Are you pregnant? Nursing?
MUSCLES, BONES, JOINTS (joint pain,
stiffness, swelling, cramps, arthritis, etc.)
SKIN (pimples, warts, growths, rash, etc.)
NEUROLOGICAL (numbness, headache,
seizures, etc.)
PSYCHIATRIC (anxiety, depression, insomnia)
ENDOCRINE (diabetes, hypothyroid, etc.)
BLOOD / LYMPH (bleeding, high cholesterol,
anemia, sicle cell, blood transfusions, etc.)
ALLERGIC / IMMUNOLOGIC (sneezing,
swelling, redness, itching, hives, lupus, etc.)
CANCER (please list type)
OTHER
FAMILY HISTORY
Please note any family history (parents, grandparents, siblings: living or deceased) for the following conditions:
DISEASE/CONDITION
YES
NO
RELATIONSHIP TO YOU
Glaucoma
Macular Degeneration
Cataract
Retinal Detachment/Disease
Diabetes
High Blood Pressure
Crossed Eyes/ Lazy Eyes
Blindness
Cancer
Heart Disease
Lupus
Thyroid Disease