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Download HEALTH HISTORY AIDS/HIV Yes Yes Lazy Eye Yes Yes Arthritis
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HEALTH HISTORY Please complete both front and backsides of this form Patient’s Name____________________________ Birth Date______________________________ Family Physician________________________(M.D or D.O.) Physician Family Address____________________ City___________________ State______________ Zip Code_____________ Phone Number_________________ Please circle to indicate if you have had any of the following. Also please circle to indicate if a blood relative has had any of the following problems. Yourself Family AIDS/HIV Arthritis Asthma Cancer Chemical Dependency Diabetes Drug Sensitivity Emphysema Heart Disease Hepatitis(Type____) High Blood Pressure Kidney Disease Lupus Migraine Headaches Muscular Dystrophy Multiple Sclerosis Stroke Thyroid Condition Tuberculosis Glaucoma Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yourself Lazy Eye Crossed Eyes Wandering Eyes Double Vision Spots or Floaters Light Flashes Chronic infection Uveitis or iritis Eye Surgery Temporary loss of vision Eye injury Dry Eyes Cataracts Retinal Disease Macular Degeneration Dry Eyes Are you pregnant? Alcohol Abuse Tobacco Use Please note below any other history of significant medical or eye problems. Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Family Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Medications List medications you are currently taking including eye Future appts: Updates/Additions List any changes or additions to medication previously noted on the left. drops: ________________________________ ________________________________ ________________________________ _______________________Date_________ ________________________________ ________________________________ ______________________________ _______________________Date_________ ___________________________________________________________________ Signature of Patient (Guardian if patient is a minor) ________________________ Date FUTURE APPOINTMENTS: Please note any updates to your medical or eye history _________________________________________________________Date____________ Date____________ I have indicated updates or there are no changes in the above information: ____________________________ ______________________ Signature Date ____________________________ ______________________ Signature Date
