Name __________________________________ Date___________ Race/Ethnicity: _______________
Past Medical History
Major surgeries/hospitalizations/events:___________________________________________________
Allergies to drugs/environment:___________________________________________________________
Severity: very mild/mild/moderate/severe
Reaction: rash/breathing/nausea/other:______________
Please circle or list any ongoing medical concerns associated with the following:
Weight loss/gain, fatigue, chronic fever? or none____________________________________________
Ear/nose/throat/sinuses? or none _______________________________________________________
Heart--chest pain, irregular heartbeat, high blood pressure? or none ___________________________
Respiratory--coughing, shortness of breath? or none ________________________________________
Gastrointestinal--heartburn, stomach pain, diarrhea? or none ________________________________
Skin--rashes, dryness? or none __________________________________________________________
Muscles/bones--arthritis, muscle aches? or none ___________________________________________
Neurologic--numbness, tremors, headaches? or none _______________________________________
Endocrine--diabetes, thyroid? or none ___________________________________________________
Blood/lymph--high cholesterol, anemia? or none __________________________________________
Mental--depression, Alzheimers? or none _________________________________________________
Family/Social History
Family medical history/eye conditions: ____________________________________________________
Preventative care (optional):______________________________________________________________
Social history: Smoking currently? Y / N Past? Y / N Packs or cig./day? _________ Alcohol use:_____
Nutrition history (optional): ______________________________________________________________
Developmental history (optional): _________________________________________________________
Medications & dosages: ________________________________________________________________
Supplements: _________________________________________________________________________
Please circle/list the main concerns with your eyes: Blur (right/left) (far/near), double vision, pain,
burning, gritty, itching, dryness, redness, watering, discharge, floaters, flashes, poor night vision, light
sensitivity, other: ____________________________________________________________________
Any eye conditions: Cataract, lazy eye, retinal detachment, dryness, macular degeneration, glaucoma,
crossed eyes, other: __________________________________________________________________
Eye surgeries or injuries: _______________________________________________________________
Contact lenses Brand: ____________________ Power/BC/Diam: R________________L_____________
Eye drops: ___________________________________
Interested in LASIK info ?: Y / N
Supplements? Y / N Dilation to check for retinal conditions? Y / N
Thank you!