2013 Patient Medical History
Date of Birth: _____________________ Emergency Contact/Phone:________________________
Name: ___________________________
Pharmacy:____________________________________ Family Physician: _________________________ Referring Doctor: _______________________________ Do you wear? Glasses Contact Lenses (What type?) _______________________ □ No Glasses or Contacts Ethnicity: Hispanic Preferred Language: English / Other _____________ Race: ________________________________
Medications: Please list below (or provide a list of) all medications & non-prescription drugs.
Currently taking NO medications_______________________________________________________________

Have you ever used Flomax or Avodart? Yes No Are you allergic to Latex: Yes No
List all known medical allergies: ____________________________________________________________
___________________________________________________________________ □ No Known Allergies
Patien t Ocu
History: Have you been diagnosed with any of the following in the past?
□ Other Eye Disease ________________________ Cataracts. Cataract Surgery? Date: Right_________ Left___________ By: _________________ Laser treatments to your eyes? Date: Right_________ Left___________ By: _________________ Retina Surgery? Date: Right_________ Left___________ By: _________________ Have you had any eye surgeries (including laser treatments)? If so, give reason _______________________________________________________________ Patient Medical History: Have you been diagnosed with any of the following in the past?
Heart Disease/Carotid Artery Disease □ □ Autoimmune Disease (Type)____________________ □ □ Diabetes (Type I or II)_______# of years __________ □ Cancer (Type)_______________________________ Any other disease ______________ □ □ Permanent Defect from Illness or injury__________ For female patients, are you currently pregnant or nursing? Yes No Surgical History: (Please Include Date and Type)________________________________________________
Social History
Have you smoked more than 100 cigarettes in your lifetime? Yes No Are you using or have you ever used recreational (including IV) drugs? Yes No Family History: Has anyone in your family (blood relative) had any of the following? (Please list relationship
to patient)
□ Retinal Detachment ______________________ Diabetes (IDDM/Type 2) ___________________ Diabetic Retinopathy ______________________ Corneal Disease ________________ □ □ High Blood Pressure ______________________ Heart Disease ___________________________ Retinitis Pigmentosa ____________ □ □ Other General Health Problems _______________
Date of Last Eye Exam
: __________________ Where? : ______________________
Occupation: ___________________________
Hobbies: _________________________________________
Reason for today’s visit

Any medications for your eyes (prescription or over-the–counter) __________________________


Ocular Complaints:
(Check all that apply)
□ Blurred Vision □ Double Vision □ Contact Lens Problem □ Problems in school □ Redness □ Dry Eye □ Burning □ Itching □ Watering □ Irritation □ Injury □ Pain □ Light Sensitivity □ Flashes □ Floaters Optical Complaints: (Check all that apply)
Happy with glasses? □ YES □ NO Please explain:_______________________________________________________

Happy with contacts? □ YES □ NO Please explain:_______________________________________________________
Review of Systems: Do you currently have any of the following symptoms?
Not currently experiencing any of the symptoms below
□ □ Heat Intolerance

Source: http://www.have2020.com/images/pdf/AdultHistory-Form.pdf

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