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Medical HX Today’s Date ____/___/_____ ____________________________________________ Date of Birth ____/___/______ Last name First name Middle name/Initial Last Eye Exam ____/____/________ Time in: _________ Appointment at: ________ [ ] New [ ] Established If established only need changes since last exam. MEDICAL HISTORY / CONDITIONS / MEDICATIONS Please Check All That Apply [ ] Respiratory [ ] Diabetes [ ] Asthma [ ] Cardiovascular [ ] Thyroid Disease [ ] Neurologic [ ] Genitourinary [ ] Psychiatric [ ] High Blood Pressure [ ] Hormone Replacement [ ] Musculoskeletal [ ] High Cholesterol [ ] Immunologic [ ] Ears, Nose, Mouth, Throat [ ] Blood Disease / Lymphatic Disease [ ] Allergies [ ] Endocrine [ ] Skin Condition [ ] Gastrointestinal [ ] Significant loss or gain of weight in the last year [ ] Recurrent fever within last year Please List your specific diagnosis(s) from above: ________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ If Diabetic, Last Blood Sugar: _________ and Last a1c: _____________ List All Medications You Take: _______________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ List All Medications You are Allergic to: ________________________________________________________________ ________________________________________________________________________________________________ List All EYE Disease, Injuries or Surgeries you have had: ___________________________________________________ ________________________________________________________________________________________________ List family member and their medical conditions: ________________________________________________________ ________________________________________________________________________________________________ List family member and their eye disease/conditions: ____________________________________________________ ________________________________________________________________________________________________
