Have2020.com
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
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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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