Patient Form Name* First Last Personal/Family HistoryArthritis*YesNoWho?(Blood Related Only)Cancer*YesNoWho?(Blood Related Only)Diabetes*YesNoWho?(Blood Related Only)Heart Disease*YesNoWho?(Blood Related Only)High Blood Pressure*YesNoWho?(Blood Related Only)High Cholesterol*YesNoWho?(Blood Related Only)Thyroid Disease*YesNoWho?(Blood Related Only)Lupus*YesNoWho?(Blood Related Only)Stroke*YesNoWho?(Blood Related Only)Kidney Disease*YesNoWho?(Blood Related Only)Multiple Sclerosis*YesNoWho?(Blood Related Only)Crossed Eye*YesNoWho?(Blood Related Only)Lazy Eye*YesNoWho?(Blood Related Only)Macular Degeneration*YesNoWho?(Blood Related Only)Retinal Detachment*YesNoWho?(Blood Related Only)Glaucoma*YesNoWho?(Blood Related Only)Cataracts*YesNoWho?(Blood Related Only)Blindness*YesNoWho?(Blood Related Only)Eye HistoryDate of Last Eye ExamBy whom?Any previous eye surgeries or injuries?Date of Eye Surgery or InjuryCurrently Wears Glasses?YesNoCurrently Wears Contacts?YesNoBrand of ContactsYour reason(s) for visiting our office today:(please Check all that apply) Comprehensive Exam Blurred computer vision Eyes feel dry Eyes feel tired Headache Night vision problems Pain or discomfort in eyes Light sensitivity Blurred near vision Eye watering/tearing Flashes of lights Double vision Blurred distance vision Eyes itch Floating spots in vision Lost or broken glasses Current Medications(prescription and over-the-counter) Medication Allergies Social HistoryHeightWeightAre you Pregnant or nursing?YesNoHave you ever smoked?YesNoHow long ago did you quit?Do you drink?YesNoHow many daily?Last Blood Pressure Reading?PulsePatient SignatureDate Date Format: MM slash DD slash YYYY If patient is a minor what is the relationship?
