Medical History Form

MEDICAL HISTORY QUESTIONNAIRE

Name*

Date

Address

Phone*

Work Phone

Birthday

Guardian (if applicable)

Social Security #

How many years since your last eye exam?

How many years since your last medical exam?

SOCIAL HISTORY

This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.

Occupation

Do you drive?

If yes, do you have visual difficulty when driving?

Do you use tobacco products?

Do you drink alcohol?

Do you use illegal drugs?

Have you ever been exposed to or infected with:

Have you ever had a blood transfusion?

MEDICAL HISTORY

Do you have any allergies to medications?

List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies)

Are you pregnant and/or nursing?

List all major injuries, surgeries and/or hospitalizations you have had

Do you wear glasses?

Do you wear contact lenses?

Type of contact lenses

Are they comfortable?


Sports & Safety Eyewear
Many eyeglass and control lens wearers have hobbies and job needs that require a special pair of glasses. We encourage all of our patients to wear Sports/safety eyewear during these activities. The eyewear your receive to wear on a daily basis are dress eyewear only -- they do not meet the Safety Eyewear Standards.

Have you or any of your blood relatives ((living or deceased) had any of the following?

Diabetes

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High Blood Pressure

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Heart Disease

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Thyroid Disease

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Stroke

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Cancer

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Cholesterol

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Arthritis

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Lupus

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Glaucoma

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Cataracts

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Blindness

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Macular Degeneration

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Crossed Eyes

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Lazy Eye

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Drooping Eye Lid

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Eye Injury or Infections

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Other Eye Disease

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