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Medical History

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Eye History

Reason for Visit

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Do you currently have any of these symptoms?

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Do you currently take any of these medications?

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Have you had any eye surgeries? Please describe ("N/A" if none)

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Primary Vision Correction

Contact Lens Wearers only:

Type of Contacts worn in the past

Cleaner

Disposal

Wear Time

Medical History:

Medications ("N/A" if none)

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Over the Counter Medications ("N/A" if none)

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Vitamins ("N/A" if none)

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Drug allergies ("N/A" if none)

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Please Describe any Injuries or Surgeries you have had ("N/A" if none)

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Primary Care Physician

Last Visit

Reason

Pregnant or Nursing

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Do you have any of these medical conditions?

Diabetes

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Year Diabetes diagnosed if applicable

Hypertension

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High Cholesterol

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Thyroid Conditions

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Heart Conditions

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Cancer

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Other

Family Medical History

Does anyone in your family have any of these medical conditions?

High Blood Pressure

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Diabetes

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Thyroid

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Cancer

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High Cholesterol

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Heart Conditions

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Other

Family Eye History

Does anyone in your family have any of these eye conditions?

Unknown family eye history

Macular Degeneration

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Glaucoma

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Retinal Detachment

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Blindness

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Cataracts

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Lazy/Crossed Eye

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Review Of Systems

General

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Skin

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Ear/Nose/Throat

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Respiratory

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Musculoskeletal

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Psychiatric

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Endocrine

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Blood/Lymph

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Neurological

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Immune

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Genitourinary

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Gastrointestinal

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Cardiovascular

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Social History

Hobbies

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Smoking Status

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Type

How long

Alcohol Use

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Type

How long

Illegal Drug Use

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Type

How long

Race

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Ethnicity

Preferred Language

STD

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Patient information

Billing information

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Medical History