Dr. Don Steensma 465 W. Channel Islands Blvd, Port Hueneme, CA 805/486-3585

Name:*                                                          Date:* 
Last eye examination:    Last thorough medical exam: 
Do you take any medications?

   List on the next page in Section A

Have you had any major illnesses or injuries?

   List on the next page in Section B

Have you had any eye surgeries?

   List on the next page in Section C

Do you have allergies to any medications?

  

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?


Do you drink alcohol?


Do you use illicit drugs?


Do you smoke?


Does your vision limit any activities of daily living?


Patient signs:*  Doctor signs: ________________________
 
Section A - Medication List
Medication Why Taken Medicaton Why Taken
 
Section B - Major Illnesses & Injuries
 
Section C - Eye Surgery History
 
Section D - Other Current Health Problems
 
  

#1 Favorite optometrist

Winner of the 2011, 2012, 2013, 2014, 2015, 2016 & 2017 Ventura Star newspaper Readers Choice Contest:

(7 years in a row!)

Winner of the 2015 & 2016 Ventura Reporter "Best of Ventura County":