Download Comprehensive Patient History

METRO EYE CARE
Comprehensive Patient History
Name:_________________________________ Date of Birth: _________________
Review of Systems
Do You Have?
Yes
Past Medical History
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Distortion of vision………….…….
Have you ever had ?
No
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Flashes…………………………... □
Abnormal sensitivity to light…….□
Halos around lights…………… □
Problems with glare……………..□
Red eye…………………………. □
Eye discomfort…………………. □
Eye dryness……………………...□
Eye itching………………………..□
Pressure in or behind the eye… □
Tearing of the eyes…………… □
Discharge……………………… □
Crusting or red eyelids………… □
Double vision…………………… □
Headaches……………………… □
Jagged lines in vision……………□
Decreased vision………………..
Date: ___________________
Yes
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Eye injury…………………………… □
Serious eye infection……………… □
Lazy eye……………………………. □
Droopy eyelid……………………….□
Corneal disease…………………… □
Cataract…………………………….. □
Retinal disorder……………………..□
Eye tumor……………………………□
Eye turning in or out………………..□
Diabetes……………………………..□
High blood pressure………………..□
Heart disease……………………….□
Lung disease………………………. □
Neurological disease……………….□
Thyroid disease……………………..□
Migraine…………………………… ..□
Lupus………… ……………………..□
Asthma…………………………… …□
Stroke……………………… ……….□
Glaucoma………………… …………□
Cancer………………..……………...□
Cholesterol……………………….….□
Eye surgery………………………….
Other illnesses:___________________________
________________________________________
Other surgeries: ___________________________
________________________________________
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No
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Comprehensive Patient History
Name:_________________________________ Date of Birth: _________________
Family History
Yes
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Macular Degeneration…………….□
Blindness…………………………...□
Retinal Detachment………….……□
Glaucoma…………………………..□
Do you wear contact lenses?…….□
Cataracts……………………………
No
Social history
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Gas Perm.
Disposable
YES
No
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Are you pregnant…………………□
Do you use a computer often…...□
Do you consume alcohol…… …..□
Other eye disorders……………...□
Do you wear glasses…………. …□
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Do you smoke……………………
If so, please provide any information you may have:
Soft
Date: ___________________
If so, what purpose:
Toric
Distance
Progressive (Varilux)
Reading
Trifocal
Bifocal
Half /reader
Extended wear
Name of Contact Lenses:
Present Prescription:
Base Curve (B.C.)
Pharmacy Name:_________________________________
Diameter (Dia.)
Pharmacy Address:_______________________________
_______________________________________________
Pharmacy Number:_______________________________
List Allergies to medications if any:
Present Medication List:
Are you taking Flomax?
Dosage
Yes
Freq.
No
1. ___________________________________
1. _______________________/____________/_________
2. ___________________________________
2. _______________________/____________/_________
3. ___________________________________
3. _______________________/____________/_________
4. ___________________________________
4. _______________________/____________/_________
5. ___________________________________
5. _______________________/____________/_________
6. ___________________________________
6. _______________________/____________/_________
7. ___________________________________
7. _______________________/____________/_________
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