Download SIGHT WEST HARTFORD History Form Name: Last _________

SIGHT
WEST HARTFORD
History Form
Name: Last _________________________________________ First ______________________________ M.I. ______
Address: _____________________________________ City: ____________________ State: _______ Zip: __________
Home Phone: _____________________ Cell Phone: ___________________ Business Phone: _____________________
E-Mail Address: _________________________________________________
Date of Birth: __________________ Age: _________ Last 4 digits of Social Security# : _________________________
Marital Status:
 Single
 Married
 Divorced
 Widowed
 Other
Employment Status:
F/T Employed
 P/T Employed
 Self Employed
 Unemployed
Retired
F/T Student
P/T Student
 Other
Employer: ___________________________________________ Occupation: __________________________________
How were you referred to our office?
Friend or Family Member _____________________________
Insurance Company
Family Doctor ______________________________________
Internet
Ophthalmologist ____________________________________
Other ______________________
Do you……(check box if your answer is yes)
 Wear prescription glasses? How old are they?  1 year  2 years  3+ years

 Single Vision
 Progressives

 Bifocal Over the Counter Readers
 Have more than one pair of current prescription eyeglasses?
 Work at a computer? How much? _____ Hrs/week
 Spend time outdoors? How much? _____ Hrs/week
 Participate in sporting activities? ____________________________________________________________________
 Have prescription sunglasses?
 Have any issues with your current eyeglasses?
 Too heavy
 Lenses are too thick
 Uncomfortable
 Nose pads
 Want new style
 Difficult to clean
 Other ____________________________________________________________
Plan on purchasing new glasses at the end of today’s exam?
 Only if I have a prescription change
 Prefer not to wear your glasses at times?
 Wear contact lenses?
 Daily disposable  Two week disposable  Monthly disposable
 RGP (Hard lenses) Specialty Lenses
 Use contact lens solution? If yes, which brand?___________________________________
 Have interest in a “test drive” of the latest contact lens designs?
Chief complaint:
Reason for today’s visit?
________________________________________________________________________________________________
Visual and Ocular History:
Date of last Eye Exam ___________________ Were you dilated? □ Yes □ No
Doctor’s Name_____________________________________________________________________________________
Diagnosis/Recommendations__________________________________________________________________________
Have you ever had vision therapy?  Yes  No
If yes: When? ________________________________
Have you ever had an injury to or surgery on your eyes?
 Yes
 No
If yes: When? ________________________________
Are you presently experiencing any of the following? (Please check all that apply and specify frequency)
_____Eye Pain or Soreness
_____Loss of Vision/ Loss of Side Vision
_____Headaches/Migraines
_____Difficulty with depth perception
_____Burning of the eyes
_____Difficulty with driving
_____Watering/tearing of the eyes
_____Difficulty with sports performance
_____Itchy eyes
_____Visual discomfort while using computer
_____Redness of the eyes
_____Slow reading
_____Glare/Light sensitivity
_____Difficulty with reading comprehension
_____Blurred vision
_____Lose place while reading
_____Double vision
_____Short attention span in visual tasks
_____Eye(s) turn in, out, up or down
_____Clumsiness/bumping into things
_____Flashes of light
_____Sleepy/tired when doing visual work
_____Floaters
_____Backaches or neck aches
_____Dry Eyes
_____Posture problems
_____Sties/Chalazion
_____Other:___________________________________
Medical History:
Date of last Medical Exam: __________________
Physician’s Name______________________________ Address______________________________________________
Are you experiencing or have you ever experienced the following? (please check all that apply)
___High blood pressure
___Diabetes ___Arthritis
___Asthma ___ Kidney Disease
___Cancer ___Allergies ___Heart disease ____Immune Function Problems
___Cataracts ___Glaucoma ___ Macular degeneration ___Retinal disease ___Blindness
___Anemia ___COPD/Emphysema ___Thyroid Disease ___Seizures
___Other:____________________________________________________________________________
Does anyone in your immediate family experience any of the above?  Yes  No
If yes, which?_________________________________________________________________________
Do you take any medications?  Yes  No
If yes, please list them here: ______________________________________________________________
Are you allergic to any medications:  Yes  No
If yes, specify: ________________________________________________________________________
Have you ever suffered a head or brain injury?  Yes  No
If yes, please explain____________________________________________________________________
Have you ever been exposed to or infected with the following? (please check all that apply)
___Gonorrhea ___Hepatitis ___HIV ___Syphilis ___TB
Nutrition/Diet:
Do you have any food allergies or sensitivities?  Yes  No
If yes, please list them here: ______________________________________________________________
Does your diet include: _____Animal protein _____ Seafood _____ Vegetables _____ Fruit
_____Dairy _____ Pasta/Bread _____ Other _________________________
Which vitamins/supplements do you take on a regular basis:
Vitamins: _____________________________________________________________________
Supplements: __________________________________________________________________
Lifestyle:
Are you experiencing: Sleep Issues _____ Eating Issues _______ Digestive Issues ______
Do you drive?  Yes  No
Do you play sports or exercise on a regular basis? . Yes . No
If so, what do you do? ________________________________________________________________________
Any life stressors: ___________________________________________________________________________________
Do you smoke, drink, use drugs?  Yes  No
If so, please clarify including frequency ___________________________________________________________
Please give a brief description of yourself and your interests.
__________________________________________________________________________________________________
Do you have children?  Yes  No Ages? ________________________________________________________
Do you have family members in need of eye care?  Yes  No
If yes: When? ________________________________________________________________________
Emergency Contact__________________________________________ Phone_________________________________