Health History and Medications Form

Health History and Medications Form

Health History and Medications Form

Health History and Medications Form

Health History and Medications Form

Please take a moment complete the vital information on both sides. If you have any questions or need clarification, please ask your receptionist or technician. If you need extra paper for any section below, please ask your receptionist.

Select Location
First Name
Last Name
Today’s Date
Date of Birth
Height
Weight
Primary Care Physician
Last physical exam
Preferred Pharmacy
Last physical exam
How did you hear about us? Please check one
Other
MEDICATIONS: Please list any prescribed and over-the-counter medications you are taking along with the dosage.
ALLERGIES: Please list all medications that you are allergic or sensitive to:
ALLERGIES (OTHER):
Food (please list)
Chemical (please list)
PAST MEDICAL HISTORY: Within the last five years, please list any:
Prior Hospitalizations
Prior illnesses
Prior surgeries/operations
OPHTHALMOLOGY SURGERY HISTORY:
Please list all prior eye surgeries. Please include date of surgery and name of surgeon:
PAST OCULAR HISTORY:
Eye-Care Professional’s name
Last eye exam
Please check all that apply
SOCIAL HISTORY:
Alcohol use
Smoker
Annual flu shot/Influenza vaccine
Occupation
Employer
Hobbies
REVIEW OF SYSTEMS: Please list your current health problems. Check all that apply:
General/Constitutional:
Skin and/or Breast:
Ears:
Nose:
Mouth/Throat:
Thyroid:
Respiratory:
Cardiovascular:
Digestive:
Urinary:
Musculo-skeletal:
Neurological:
Endocrine:
Blood/Lymph:
Psychiatric:
Allergic/Immunologic:
Other
FAMILY HISTORY: Please select all that apply and list the family member affected:
Glaucoma
Macular Degeneration
Strabismus (Crossed Eyes)
Amblyopia (Lazy Eye)
Retinal Detachment
Blindness
High Blood Pressure
Heart Disease
High Cholesterol
Diabetes
Migraines
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