New Patient Health and Ocular History

New Patient Medical and Ocular History
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date

Primary Physician
When was your last physical exam?

Check the Box for Any Conditions that Apply:

Rows	You	Mom	Dad	Sib
Diabetes
High Blood Pressure
Thyroid Disease
Heart Disease
Cancer

Describe any checks above as needed (when diagnosed, explanation of problem)
If you are diagnosed with diabetes or borderline diabetes, please answer the following questions about your condition:
Type 1 DiabetesType 2 DiabetesOther
When were you diagnosed?
Last HbA1c Level or Glucose Range
PregnantNursing
YesNoAssisted LivingNursing HomeOther
List major injuries or surgeries, including approximate year:
List any other medical conditions you have, including non-drug allergies:
List vitamins/supplements you take: *
List any drug allergies you have:*
List all Rx and over-the-counter medications you take, including dosage: *

Who was your previous eye doctor?
When was your last eye exam?
What is the primary reason for your upcoming appointment?*
List any additional vision complaints you are having such as:

Check all that apply:

Rows	You	Mom	Dad	Sib
Glaucoma
Macular Degeneration
Retinal Problems
Cataracts
Lazy Eye / Eye Turn

Describe any checks above as needed (when diagnosed, explanation)
List major EYE injuries, infections, or surgeries, including approximate year:
List any other eye problems you have had in the past:
List any EYE drops you use (prescription or over-the-counter)
YesNo
What brand and powers are you wearing?
Any problems with comfort?
Vision complaints?
What disinfecting solution do you use?
What is your average wear time?
How often do you replace them?
How old is your current pair of lenses?