Wasatch view eye care

Medical History
Name_______________________________________________________ Gender: M F Date of Birth_____________ Age________ _ What is the reason for your visit?________________________________________________________________________________________ Are you taking: Accutane Imitrex Cordarone Prednisone Medications_________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Drug Allergies: ______________________________________________________________________________________________________ Medical History
Yes No Bleeding Disorder______________________________ Yes No Neurological Disease____________________________ Circle Yes or No
Yes No Heart Disease__________________________________ Yes No Diabetes; taking: Insulin / Medications / Diet-Exercise
Yes No Immune Disease________________________________ Yes No Digestive Disease_______________________________ Yes No Muscle/Skeletal Disease_________________________ Yes No Lung/Breathing Disease__________________________ Yes No Kidney/Bladder Disease_________________________ Yes No Cancer_______________________________________ Yes No Blood Disorder_________________________________ Yes No Mental Health Concerns_________________________ Yes No Skin Disease___________________________________ Yes No Liver Disease__________________________________ Yes No Thyroid Disease________________________________ Yes No Food / Seasonal Allergies________________________ Yes No Epilepsy______________________________________ Yes No Keloid Scars___________________________________ Yes No Other________________________________________ Yes No Currently pregnant or nursed in the last 3 months? Social History
Use of Alcohol: Never Rarely Moderate Daily
Use of Tobacco: Never Previously, but not in the past ________ year(s) Current packs/day _________
Use of drugs: : Never Rarely Moderate Daily
Eye History
Yes No Other________________________________________ Circle Yes or No
Yes No Do your eyes feel gritty or scratchy? Yes No Do your eyes frequently turn red? How often do you use artificial tears?_______________________ Contact Lens Wear
Yes No Eye Surgery_________________________________ What brand or type of contacts do you wear?__________________ Yes No Eye Injury__________________________________ How often do you replace your contacts?_____________________ What type of solution do you use?__________________________ How often do you take your lenses off?______________________ For LASIK, when did you last wear your lenses?______________ ________________________________________________________________________________________________
I hereby acknowledge the above to be true to the best of my knowledge. Signature_________________________________________________________________ Date_________________

Source: http://www.wasatchview.com/pdf/Medical_History.pdf

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