Patient Medical Information Form

Name:* Date:*

Last eye examination: Last thorough medical exam:

Do you take any medications?

N Y List on the next page in Section A

Have you had any major illnesses or injuries?

N Y List on the next page in Section B

Have you had any eye surgeries?

N Y List on the next page in Section C

Do you have allergies to any medications?

N Y

Do you currently have any problems in the following areas?
If needed continue on next page in Section D

Eyes (poor vision, eye pain, tearing, redness, itching, burning, spots)	N

General/Constitutional (fever, heat stroke, weight loss or gain, unusually tired)	N

Ears, Nose, Throat (hard of hearing, stuffy nose, ear ache, cough, etc.)	N

Cardiovascular (high BP, racing pulse, etc.)	N

Respiratory (congestion, wheezing, shortness of breath, etc.)	N

Gastrointestinal (stomach upset, diarrhea, constipation, ulcers, etc.)	N

Genital, Kidney, Bladder (painful/frequent urination, yellow jaundice, etc.)	N

Females (Are you pregnant? Nursing?)	N

Muscles, Bones, Joints (joint pain, stiffness, swelling, cramps, arthritis, etc)	N

Skin (warts, growths, rash, skin cancer, etc.)	N

Neurological (numbness, headache, seizures, paralysis, etc.)	N

Psychiatric (anxiety, depression, insomnia)	N

Endocrine (diabetes, hypothyroid, etc.)	N

Allergic / Immunologic (sneezing, swelling, redness, itching, hives, lupus, etc.)	N

Has any member of your family had these diseases (check all that apply)? And who?

Macular Degeneration

Glaucoma

Ever have a blood transfusion?

N Y

Do you drink alcohol?

N Y

Do you use illicit drugs?

N Y

Do you smoke?

N Y

Does your vision limit any activities of daily living?

N Y

Patient signs:*

Doctor signs: ________________________

Section A - Medication List

Section B - Major Illnesses & Injuries

Section C - Eye Surgery History

Section D - Other Current Health Problems