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Sunset Eye Clinic, LLC 1. PATIENT INFORMATION Name:________________________________________Age _________________________ Date:____________________________ Occupation __________________________Employer____________________________Last Medical Exam ____________________ Medical Doctor’s Name_____________________________________Dr’s Phone Number___________________________________ 2. EYE HEALTH HISTORY (Please check any symptom / condition that applies) Need new glasses / contact lens Blurry Distance Vision Blurry Near Vision Tired Eyes Computer Eye Strain Itchy Eyes Cataracts Watery Eyes Macular Degeneration Burning Glaucoma Infection Eye Injury Sties Other Lasik/Refractive Surgery Date of Last Eye Exam:_______________Do you wear contact lenses (Y / N) Are you interested in contact lenses (Y / N) Do you wear glasses (Y / N) Do you use a computer regularly (Y / N), if so, how many hours:____________________ 3. Lazy Eyes Double Vision Loss of side Vision Headache Light Sensitivity Flashes/floaters in vision Temporary Vision Loss Foreign Body sensation Dry Eyes Redness Review of Systems (Do you currently, or have you ever had any problems in the following areas, check all that apply) Constitutional Ear, Nose, Throat, Mouth Fever Allergies/Hay Fever Weight Loss Sinus Congestion Weight Gain Runny Nose Endocrine Post-Nasal Drip Thyroid/other glands Chronic Cough Psychiatric Dry Throat/ Mouth __________________ Allergic/Immunologic __________________ Respiratory High Blood Pressure Bones/Joints/Muscles Asthma Vascular Disease Rheumatoid Arthritis Chronic Bronchitis Gastrointestinal Muscle Pain Emphysema Diarrhea Joint Pain Vascular Constipation Lymphatic/Hematologic Diabetes Genitourinary Anemia Heart Pain Kidney/Bladder Bleeding Problems High Cholesterol Integumentary/Skin __________________ If you answered YES to any of the above or have a condition not listed, please explain: _________________________ _________________________________________________________________________________________________ List any medications you take including birth control, over the counter medications, eye drops, and home remedies: ________________________________________________________________________________________________ ________________________________________________________________________________________________ Allergies to any medications:__________________________________________________ Are you pregnant/Nursing ( Y / N ) 4. FAMILY HISTORY (Please check if your relatives had / have any of the following conditions) Blindness Crossed Eyes Macular Degeneration 5. Social History Do you drive? No Retinal Problems Diabetes High Blood Pressure Kidney Disease Cancer Cataract Thyroid Disease Glaucoma Lupus Arthritis Other (This information is kept confidential. However, you may discuss this portion with the doctor.) Yes If yes, do you have visual difficulty when driving? No Yes Do you use cigarettes/tobacco?________________Alcohol?___________________Other Substances?______________ Have you ever been exposed to or infected with: Gonorrhea Doctor’s Signature_______________________________ Hepatitis HIV Syphilis
