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 
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

Favorite optometrist

-  Winner of the 2011, 2012, 2013, 2014, 2015,
2016, 2017, 2018, 2019

Ventura Star newspaper "Readers Choice" contest

-  Winner of the 2015, 2016, 2018 & 2019

Ventura Reporter "Best of Ventura County" contest