Medications must be listed
NAME:
______________________________
CHART
#:_____________________________
DATE:
_______________________________
MEDICAL
DR.: _______________________
REVIEW OF SYSTEMS/PAST
MEDICAL HISTORY:
DO YOU NOW HAVE/HAD PROBLEMS
WITH ANY OF THE FOLLOWING. IF YES,
EXPLAIN:
EYES [
] NO [ ] YES
________________________________________________________
EARS, NOSE, THROAT [ ]
NO [ ]
YES ________________________________________________________
HEART, BLOOD, VESSLES,
HBP [ ] NO [ ] YES
________________________________________________________
LUNGS/ BREATHING [ ]
NO [ ]
YES ________________________________________________________
STOMACH, INTESTINES,
LIVER [ ] NO [ ] YES
________________________________________________________
KIDNEYS, BLADDER,
GENITAL [ ]
NO [ ]
YES ________________________________________________________
MUSCLES, JOINTS [ ]
NO [ ]
YES ________________________________________________________
SKIN / BREASTS [ ]
NO [ ]
YES ________________________________________________________
BRAIN, SPINAL CORD,
NERVES [ ] NO [ ] YES
________________________________________________________
PSYCHIATRIC [ ]
NO [ ]
YES ________________________________________________________
DIABETES, THYROID [ ]
NO [ ]
YES ________________________________________________________
BLOOD PROBLEMS, SWELLING [
] NO [ ] YES
________________________________________________________
ALLERGIES, IMMUNE [ ]
NO [ ]
YES ________________________________________________________
OTHER [ ]
NO [ ]
YES ________________________________________________________
PAST SURGICAL HISTORY:_____________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
PREVIOUS EYE PROBLEMS OR
SURGERIES: _____________________________________________________________
______________________________________________________________________________________________________
ARE YOU CURRENTLY
WEARING: GLASSES? _______ SOFT
CONTACTS? _______ HARD CONTACTS?_________
ARE YOU INTERESTED IN SOFT
CONTACTS? ____________________
HARD CONTACTS?
____________________
ARE YOU INTERESTED IN
REFRACTIVE SURGERY? ______________________________________________________
MEDICATIONS YOU ARE TAKING:
______________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
DRUG ALLERGIES:
_____________________________________________________________________________________
_______________________________________________________________________________________________________
SOCIAL HISTORY: MARITAL
STATUS: [ ] M [ ]
S [ ]
W [ ]
D
SMOKER: [ ]
NO [ ]
YES - AMOUNT ________________________________________
DRINK ALCOHOL: [ ]
NO [ ]
YES - AMOUNT ________________________________________
CURRENT OCCUPATION:
__________________________________________________________________
FAMILY HISTORY - EYES: GLAUCOMA [
] NO [
] YES
_____________________________________________
CATARACTS [ ]
NO [ ]
YES _____________________________________________
MACULAR DEGENERATION [ ]
NO [ ]
YES _____________________________________________
OTHER
[ ] NO [ ] YES
_____________________________________________
FAMILY HISTORY - GENERAL
HEALTH: HEART DISEASE [
] NO [
] YES
_______________________________
HIGH BLOOD PRESSURE [ ]
NO [ ]
YES _______________________________
DIABETES [ ]
NO [ ]
YES _______________________________
CANCER [
] NO [
] YES _______________________________
OTHER [ ]
NO [ ]
YES _______________________________
IF YES TO ANY OF THE ABOVE,
EXPLAIN RELATIONSHIP TO PATIENT.
REVISED 01/03
REVIEWED BY: ________________________________________