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Download Name: Date: Date of Birth: of last eye exam___________ OFFICE
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Name: Date: Date of Birth: __________________________________Date of last eye exam___________ OFFICE PERSONNEL ONLY Chief Complaint:______________________________________________________________ ___________________________________________________________________________ Ocular History: ______________________________________________________________ ___________________________________________________________________________ List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, etc.) or injuries (concussion,etc.): _____________________________________________________________ ____________________________________________________________________________ EYE SURGERIES WHICH EYE YES DOCTOR YEAR NO Do you have trouble seeing to read? Do you drive? Do you have visual difficulty when driving? Do you have problems with night vision? Have you ever tried to wear contact lenses? If YES, how long? Do you currently wear contact lenses? If YES, how long with current Rx? Do you currently wear glasses? Have you ever had a blood transfusion? Do you drink alcohol? If YES: occasional 1/day Do you smoke? If YES: occasional ½ pack/day 1 pack/day +pack/day 2-3/day 4+/day Other Do you currently have any problems in the following areas? If YES, please provide information. EYES Loss of vision Blurred vision Fluctuating vision Distorted vision (halos) Glare or light sensitivity Loss of side vision Double vision YES NO Explanation of Problem EYES YES NO Explanation of Problem Dryness Mucous discharge Redness Sandy or gritty feeling Itching Burning Foreign body sensation Excess tearing or watering Eye pain or soreness Infection of eye or lid Tired eyes Crossed eyes, lazy eye Drooping eyelid REVIEW OF SYSTEMS: Please indicate and explain any problems GENERAL/CONSTITUTIONAL (fever, weight loss, other) EARS, NOSE, THROAT (stuffy nose, ear ache, cough, dry mouth etc.) CARDIOVASCULAR (high BP, racing pulse, etc.) RESPIRATORY (congestion, wheezing, etc.) GASTROINTESTINAL (stomach upset, diarrhea, constipation, etc.) GENITAL, KIDNEY, BLADDER (painful urination, frequent urination, impotence, etc.) MUSCLES, BONES, JOINTS (joint pain, stiffness, swelling ,cramps, etc.) SKIN (pimples, warts, growths, rash, etc.) NEUROLOGICAL (numbness, headache, etc.) PSYCHIATRIC (anxiety, depression, insomnia) ENDOCRINE (diabetes, hypothyroid, etc.) BLOOD /LYMPH (cholesterolemia, anemia, etc.) ALLERGIC /IMMUNOLOGIC (sneezing, swelling, redness, itching, YES NO Explanation of Problem FAMILY HISTORY DISEASE Blindness Glaucoma Arthritis Cancer Diabetes Heart disease or high BP Kidney disease Lupus Stroke Thyroid disease Other M=Mother; F=Father; S=Sibling; GP=Grandparent YES NO Relationship to Patient SOCIAL HISTORY Current Occupation: _____________________________ Education: ____________________ Marital Status: Married Single Divorced Widowed Living Arrangements: _____________ PATIENT’S SIGNATURE:________________________________________________DATE:_______ OFFICE PERSONNEL ONLY History reviewed: Date:_____________ [ ] No changes [ ] Additions as noted Tech:_______ History reviewed: Date:_____________ [ ] No changes [ ] Additions as noted Tech:_______ History reviewed: Date:_____________ [ ] No changes [ ] Additions as noted Tech:_______ History reviewed: Date:_____________ [ ] No changes [ ] Additions as noted Tech:_______ History reviewed: Date:_____________ [ ] No changes [ ] Additions as noted Tech:_______ History reviewed: Date:_____________ [ ] No changes [ ] Additions as noted Tech:_______ History reviewed: Date:_____________ [ ] No changes [ ] Additions as noted Tech:_______ History reviewed: Date:_____________ [ ] No changes [ ] Additions as noted Tech:_______ … PHYSICIAN SIGNATURE:________________________________________________DATE:_______
