Adult Health History
Name (full legal name)
First Name
Middle Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone (Cell)
Phone (Daytime)
Email
(email used primarily for appointment reminders)
Ethnicity (please select one)
Caucasian
African American
Hispanic or Latino
Middle Eastern
Asian
Hawaiian/Pacific Islander
Other
Race (please select one)
White
Black or African American
Hawaiian/Pacific Islander
Am. Indian/Alaska native
Asian
Other
Height
Weight
Prefer to decline weight
MEDICAL HISTORY
List medications you are currently taking (please include Rx, OTC, vitamins, & eye drops)
1
None
Do you have any allergies to medications?
Yes
No
Please explain
List major illnesses, injuries, surgeries, or hospitalizations you have had with approximate dates
2
None
Name and office location of your medical doctor(s)
Date of your last visit
-
Month
-
Day
Year
Date
Have you ever been treated for any of the following medical conditions?
Yes / No
Comment
High Blood Pressure
Yes
No
Heart Disease or Problems
Yes
No
Allergy or Hay Fever
Yes
No
Asthma or Lung Disease
Yes
No
Diabetes
Yes
No
Thyroid Disease
Yes
No
Arthritis
Yes
No
Cancer
Yes
No
FAMILY HISTORY
3
Yes / No
Relationship
Blindness
Yes
No
Glaucoma
Yes
No
Macular Degeneration
Yes
No
Cataracts
Yes
No
Diabetes
Yes
No
High Blood Pressure
Yes
No
Cancer
Yes
No
Heart Disease
Yes
No
Other
Yes
No
OCULAR HISTORY
Please list any past or present eye diseases, eye infections, or eye surgeries you have had
4
None
Do you wear glasses?
Yes
No
Do you wear sunglasses?
Yes
No
Do you wear contact lenses?
Yes
No
What type?
Back
Next
PERSONAL INFORMATION
What is your occupation?
Marital Status
List your hobbies/recreational activities
Do your occupation or any hobbies/recreational activities require the use of safety eyewear?
Yes
No
Do you use the computer at work or at home?
Yes
No
Do you drive?
Yes
No
Do you have visual difficulty when driving?
Yes
No
Do you use tobacco products?
Yes
No
What type/amount/how long?
Do you drink alcohol?
Yes
No
How often?
Do you use illegal drugs?
Yes
No
Have you ever been exposed to HIV?
Yes
No
Have you ever been exposed to TB?
Yes
No
REVIEW OF SYSTEMS
Do you currently have any of the following?
Yes / No
IF YES, PLEASE EXPLAIN
EYE SYSTEM- Eye injury, pain, or surgery
Yes
No
Loss of vision
Yes
No
Blurred vision
Yes
No
Tired eyes
Yes
No
Redness
Yes
No
Itching
Yes
No
Burning
Yes
No
Sandy or dry eyes
Yes
No
Excessive tears (watery eyes)
Yes
No
Vision disturbance (spots, halos, light flashes)
Yes
No
Light sensitivity / glare
Yes
No
Double vision
Yes
No
Glaucoma
Yes
No
Cataract
Yes
No
Macular degeneration
Yes
No
Diabetic retinopathy
Yes
No
Amblyopia (lazy eye)
Yes
No
Strabismus (crossed eyes)
Yes
No
Keratoconus (disease of cornea)
Yes
No
Learning disability
Yes
No
CONSTITUTIONAL (fever, weight loss, etc.)
Yes
No
EARS, NOSE, MOUTH, THORAT (sinus, chronic cough, etc.)
Yes
No
RESPIRATORY (asthma, emphysema, etc.)
Yes
No
CARDIOVASCULAR (high blood pressure, Vascular disease, etc.)
Yes
No
GASTROINTESTINAL (diarrhea, constipation, ulcers, etc)
Yes
No
GENITOURINARY (genitals, kidney, bladder)
Yes
No
MUSCLES/BONES/JOINTS (arthritis, etc.)
Yes
No
ENDOCRINE (diabetes, thyroid, etc.)
Yes
No
PSYCHIATRIC (anxiety, depression, etc.)
Yes
No
BLOOD/LYMPH (anemia, high cholesterol)
Yes
No
ALLERGIC/IMMUNOLOGIC (hay fever, lupus)
Yes
No
SKIN (rashes, measles, chicken pox, etc.)
Yes
No
NEUROLOGICAL (headaches, multiple sclerosis, etc.)
Yes
No
Submit
Should be Empty: