Medical History!

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PATIENT MED-HISTORY

Phone-() - SS #--

Do you have an appointment?

YES

Do you currently wear:

Glasses	YES	NO

Contact Lenses	YES	NO

Low Vision Aids	YES	NO

Do you currently have or have you ever had any of the following:

Eye Surgeries	YES	NO
Eye Injuries
Eye Infections
Amblyopia
Cataracts

Dry Eyes	YES	NO
Light Sensitivity
Pain
Glaucoma
Lazy Eye

Macular Degeneration	YES	NO
Eye Turn In / Out
Reading Problems
Tracking Problems
Other

Do you Have:

YES

Diabetes

High Blood Pressure

YES

Headaches

Medication - List any Medications:

Allergies - List any known Allergies:

Are you currently taking prescription or other	YES	NO
drugs? If yes, add which ones & dosage below

Do you currently have any Allergies	YES	NO
known or perceived?

Do you have problems with any of these systems? - Please check all that apply

Allergic / Immunologic	YES	NO
Arthritis
Blood / Lymph
Cardiovascular Heart Disease
Ear / Nose / Throat
Endocrine Glands
Gastrointestinal
Integument Skin

Kidney Problems	YES	NO
Musculature
Nervous
Psychiatric
Respiratory
Skeletal Bones
Thyroid Problems
Other (explain bottom of page)

Do you use - Please select all that apply

Cigarettes?	YES	NO

Alcohol?	YES	NO

Other substances?	YES	NO

Family Eye History - Anyone in patient's family (blood relative) had any of the following?

Cataracts	YES	NO
Cornea Disease
Diabetes

Glaucoma	YES	NO
Lazy Eye
Macular Degeneration

Retina Disease	YES	NO
High Blood Pressure
Other Eye Disorders

Your Surgical History- List any type of surgery and dates of surgery

Vision Correction Preferences, Interests- Put a check in any boxes that interests you

EYEGLASSES
	Extra thin and light eyeglass lenses
	Crizal anti-reflective (Glare-Free) lenses. Reduce eyestrain. Great for night vision & computers
	Sport specific frames: protective, wrap-a-round, goggles
	Sport specific Lenses:object enhancers, background muters. etc
	Invisible bifocal (No-Line progressives) - Varilux, Seiko, Zeiss, Sola, Etc.
	Lenses that auto-adjust to comfortable shades of color, based on the light (In/Out door)
	Cosmetic tinted lenses - also tones down harsh indoor light for those who are light sensitive
	Specialty Glasses - Sports Frames, Snorkel/Scuba masks, swim, ski Motorcycle, Etc.
	Discount for second pair
SUNGLASSES
	UV (Ultra-Violet) light protection
	Polaroid lenses -considerably reduces sun & reflective glare, & eliminates horizontal reflections
	Sunglasses to wear with Contact Lenses
	Discount for second pair
CHILDREN'S VISION
	I need to know at what age should children have their first eye exam
	I need to know at what age can children wear Contact Lenses
	Protective eyeglasses for sports
	I need to know the difference between Screenings & eye examinations
CONTACT LENSES
	Contacts that are comfortable ALL day long
	Disposable Contact Lenses
	Nike Maxisight Contact Lenses for sports
	Contact lenses to replace glasses
	Contact lenses that I can sleep in, wake up, and see. (a non-surgical alternative to LASIK)
	Contact lenses that require no care, to be worn for specific occasions
	Contact Lenses that correct astigmatism
	Contact Lenses that change eye color. (Even without prescription)
	Bifocal Contact Lenses

Other Information- Please elaborate on any information or from any "Other" box above.