PRECISION VISION
482 S. Main Street, Spanish Fork, UT 84660
MEDICAL INFORMATION SHEET
Patient Name: ________________________________________________ Date: ______________________
1. Past Eye History: Have you had?
□ Blurry Vision Date:______
□ Cataracts
Date:_______
□ Glasses
Date:______
□ Glaucoma
Date:_______
□ Contacts
Date:______
□ Macular Degeneration Date:_______
□ Other Eye Disease:_____________________________________________
______________________________________________________________
2. Past Medical History: Do you have?
□ Diabetes
□ Arthritis
□ Heart Disease □ High Blood Pressure
□ Arthritis
□ High Cholesterol
□ Asthma
□ Pregnant or Nursing
□ Other Medical___________________
3. Family History of Eye Diseases and relationship (father/mother/sister/brother,etc):
□ Glaucoma ______________________
□ Macular Degeneration ______________
□ Cataracts _______________________
□ Other ___________________________
4. Drug Allergies _________________________________________________________________
5. Medications: Drug Name/ Dose/ Strength/ How you take it (for example, once a day, twice a day, etc)
________________________________________ _____________________________________
________________________________________ _____________________________________
6. Family History of Eye Diseases and relationship (father/mother/sister/brother,etc):
□ Glaucoma ______________________
□ Macular Degeneration ______________
□ Cataracts _______________________
□ Other ___________________________
7. Review of Systems: Do you have? (Circle all that apply)
□Yes □No SKIN: itching, rash, tumors (growths), other ___________
□Yes □No LYMPH NODES: swelling, tenderness, other ___________
□Yes □No BONES, JOINTS, MUSCLES: muscle pain/cramps, joint pain, swelling, other ___________
□Yes □No ENDOCRINE (eg. Thyroid) fatigue, confusion, fainting, nervousness, other ___________
□Yes □No ALLERGY/IMMUNOLOGY: hay fever, hives, food allergy, other ___________
□Yes □No HEAD: headaches, dizziness, vertigo, other___________
□Yes □No EARS: hearing loss, ringing, infections, other___________
□Yes □No NOSE: bleeding, loss of smell, congestion, sinus problems, other ___________
□Yes □No THROAT: dry mouth, difficulty swallowing, other ___________
□Yes □No NECK: pain, swelling, stiffness, other ___________
□Yes □No BREASTS: tenderness, swelling, lumps, discharge, other ___________
□Yes □No BLOOD: bruise easily, prolonged bleeding, other ___________
□Yes □No RESPIRATORY: wheezing, cough, difficulty breathing, asthma, other ___________
□Yes □No CARDIOVASCULAR (heart/vessels): chest pain, swelling of limbs, shortness of breath, other __________
□Yes □No GASTROINTESTINAL (stomach/intestines): nausea, vomiting, diarrhea, other ___________
□Yes □No GENITOURNIARY (kidney/bladder): frequency, burning, pain, bleeding, infections, other ___________
□Yes □No NERVOUS SYSTEM: weakness in limbs, numbness/tingling, seizures, tremors, neuralgia, other _________
□Yes □No PSYCHIATRIC: disorientation, mood swings, anxiety, depression, other ___________
8.Social History (Please check yes or no)
Smoke
□ Yes □ No
Packs per day/Yrs.______________
Alcohol
□ Yes □ No
How much/often? ______________
Please review the information every year and then initial and date below: