"Personal Health History Form"

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Today’s Date:__________
MR#__________________
Personal Health History
Patient
Name:___________________________Occupation: ________________DOB:_______Age:______
Please explain your present eye health and vision condition (if known):
YES
NO
Do you normally wear glasses or contacts?
If YES, which do you wear most of the time?
Glasses
Contacts
If YES, how old is the prescription?________________
YES
NO
Do you have a history of any eye disease, eye surgery (including laser
surgery) or eye injuries?
If YES, please list types and dates:
YES
NO
Are your currently taking medications of any type (including vitamins and
supplements)?
If YES, please list:
YES
NO
Are you allergic to any medications?
If YES, please list medications and type of reaction:
YES
NO
Not Applicable
Are you now pregnant or breast feeding?
Medical History: (check box YES or NO. If YES, also note date when first diagnosed.)
Date
YES_______
NO
High Blood Pressure
YES_______
NO
Diabetes
YES_______
NO
Heart Diabetes (congestive heart failure, heart rhythm problem,
heart attack, murmur),
Type: _______________
YES_______
NO
Lung Disease (emphysema, asthma), Type: _______________
YES_______
NO
Liver Disease, Type: _______________
YES_______
NO
Kidney Disease, Type: _______________
YES_______
NO
Gastrointestinal Disease (Crohn’s, ulcerative colitis, peptic ulcer),
Type: _______________
YES_______
NO
Cancer, Type: _______________
YES_______
NO
Stroke or TIA’s
YES_______
NO
High Cholesterol
YES_______
NO
Thyroid Disease
YES_______
NO
Migraines
YES_______
NO
Sleep Apnea
YES_______
NO
Seizures
YES_______
NO
Blood/Bleeding Disorder (anemia, blood transfusion), Type: __________
YES_______
NO
Arthritis, Type:_______________
YES_______
NO
Emotional Illness (anxiety, depression)
YES_______
NO
Cerebral Palsy
YES_______
NO
Prematurity
Please list any other medical problems that you have been diagnosed with:___________________
Today’s Date:__________
MR#__________________
Personal Health History
Patient
Name:___________________________Occupation: ________________DOB:_______Age:______
Please explain your present eye health and vision condition (if known):
YES
NO
Do you normally wear glasses or contacts?
If YES, which do you wear most of the time?
Glasses
Contacts
If YES, how old is the prescription?________________
YES
NO
Do you have a history of any eye disease, eye surgery (including laser
surgery) or eye injuries?
If YES, please list types and dates:
YES
NO
Are your currently taking medications of any type (including vitamins and
supplements)?
If YES, please list:
YES
NO
Are you allergic to any medications?
If YES, please list medications and type of reaction:
YES
NO
Not Applicable
Are you now pregnant or breast feeding?
Medical History: (check box YES or NO. If YES, also note date when first diagnosed.)
Date
YES_______
NO
High Blood Pressure
YES_______
NO
Diabetes
YES_______
NO
Heart Diabetes (congestive heart failure, heart rhythm problem,
heart attack, murmur),
Type: _______________
YES_______
NO
Lung Disease (emphysema, asthma), Type: _______________
YES_______
NO
Liver Disease, Type: _______________
YES_______
NO
Kidney Disease, Type: _______________
YES_______
NO
Gastrointestinal Disease (Crohn’s, ulcerative colitis, peptic ulcer),
Type: _______________
YES_______
NO
Cancer, Type: _______________
YES_______
NO
Stroke or TIA’s
YES_______
NO
High Cholesterol
YES_______
NO
Thyroid Disease
YES_______
NO
Migraines
YES_______
NO
Sleep Apnea
YES_______
NO
Seizures
YES_______
NO
Blood/Bleeding Disorder (anemia, blood transfusion), Type: __________
YES_______
NO
Arthritis, Type:_______________
YES_______
NO
Emotional Illness (anxiety, depression)
YES_______
NO
Cerebral Palsy
YES_______
NO
Prematurity
Please list any other medical problems that you have been diagnosed with:___________________
YES
NO
Have you ever had any surgery (not on your eyes)?
If YES, please list types and dates:
YES
NO
Do you smoke cigarettes or use tobacco products?
NO, NOT ANY LONGER
If YES, how much or how many cigarettes per day?____________________
YES
NO
Do you drink alcohol?
OCCASIONALLY
YES
NO
Are you interested in contact lenses?
YES
NO
Are you interested in laser vision correction?
Is there a family history of the following?
(Check box YES or NO. If YES, also note relationship: father, mother, etc.)
YES
NO Cataracts
YES
NO Macular Degeneration
YES
NO Glaucoma
YES
NO Crossed or lazy eye
YES
NO Retinal Disease
YES
NO Migraine Headaches
YES
NO Diabetes
YES
NO High Blood Pressure
YES
NO Other:_____________
YES
NO Blindness or tumor/cancer of the eye
Review of Systems: Do you have any of the following symptoms now?
If NO, Please check box. If YES, please circle all words that apply.
NO
General:
fever, chills, weight loss, night sweat, scalp tenderness
NO
Ears, Nose, Throat: ear pain, facial pain, chronic cough, dry mouth, sneezing
NO
Eye:
pain, blurred vision, double vision, redness, burning, itching,
discharge, light sensitivity, flashing lights, floaters
NO
Heart:
chest pain, rapid heart beat, high blood pressure
NO
Respiratory:
shortness of breath, difficulty breathing, discolored sputum,
wheezing, congestion
NO
Digestive:
constipation, nausea, vomiting, blood in stools, black tarry
stools, diarrhea, upset stomach
NO
Genital, Kidney:
increased urinary frequency, pain with urination, impotence
NO
Muscle:
pain in joints, pain in muscles, stiffness, swelling, cramps
NO
Skin:
rash, bruising, pimples, warts, growths, redness, itching, hives, swelling
NO
Neuro:
dizziness, weakness, numbness, tingling, trouble speaking,
bowel/bladder dysfunction, loss of balance, headache
NO
Psychiatric:
Anxiety, depression, insomnia
If you answered yes to any of the above questions and are not currently receiving care for these symptoms, report
them to your family physician as soon as possible.
When did you have your last complete physical exam?
Approximate Date:__________________________Family Doctor’s name:______________________________
Please sign and date:
(first and last name)
Signature______________________________________Date________________________
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