Patient History Form Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Today's Date* MM slash DD slash YYYY Home PhoneWork/Cell PhoneLast Exam Date* MM slash DD slash YYYY By Whom* Birth Date* MM slash DD slash YYYY Name of Medical Doctor* Personal Email* Employer/Occupation How did you hear about our office? Medical HistoryDo you have any allergies to medications?* Yes No If yes, explain List any medications you take(including oral contraceptives, eye drops, over the counter medications and home remedies) List all major injuries, surgeries and/or hospitalizations you have had(including eyes or vision correction surgery) Check off any of the following that you have had Crossed Eyes Lazy Eye Drooping Eyelid Prominent Eyes Glaucoma Retinal Disease Cataracts Eye Infections/Injury Do you wear glasses?* Yes No If yes, how old is your present pair of glasses?* Would you like to be fit for contact lenses?* Yes No Do you wear contact lenses?* Yes No If yes, how old is your present pair of lenses?* Type of contact lenses* Rigid Soft Brand* Solution* Do you sleep in your contacts?* Yes No Avg. # days before removal/cleaning* Avg. # days before disposing* Family HistoryPlease note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions (not including you):Glaucoma* Yes No Relationship to You Macular Degeneration* Yes No Relationship to You Retinal Disease* Yes No Relationship to You Blindness* Yes No Relationship to You Cataract(s)* Yes No Relationship to You Arthritis* Yes No Relationship to You Cancer* Yes No Relationship to You Diabetes* Yes No Relationship to You Heart Disease* Yes No Relationship to You High Blood Pressure* Yes No Relationship to You Thyroid Disorder* Yes No Relationship to You Other Heritable Disease* Yes No Relationship to You Social HistoryThis information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.Does your vision limit your ability to drive? Yes No Do you use tobacco products? Yes No If yes, type/amount/how long Do you drink alcohol? Yes No If yes, type/amount/how long Review of SystemsDo you currently, or have you ever had, any problems in the following areas:Eyes*(loss of vision, blurred vision, distorted vision/halos, sandy or gritty feeling, tired eyes, double vision, dryness, mucous drainage, redness, burning, itching, foreign body sensation, eye pain, soreness, chronic infection, excessive tearing/watering, styes, flashes or floaters in vision) Yes No Please specify which condition from the list and explain/give details: Allergy/Immunologic*(herpes, hay fever, lupus) Yes No Please specify which condition from the list and explain/give details: Bones/Joints/Muscles*(rheumatoid arthritis, joint pain, osteoporosis, osteoarthritis) Yes No Please specify which condition from the list and explain/give details: Constitutional*(fever, fatigue, weight loss/gain, sleep problems) Yes No Please specify which condition from the list and explain/give details: Ears, Nose, Mouth, Throat*(allergies/hay fever, hearing loss, sinus congestion, post-nasal drip, dry throat/mouth) Yes No Please specify which condition from the list and explain/give details: Endocrine*(diabetes, thyroid/other glands) Yes No Please specify which condition from the list and explain/give details: Gastrointestinal*(acid reflux, diarrhea, constipation, hepatitis, gallbladder disorder) Yes No Please specify which condition from the list and explain/give details: Genitourinary*(kidney stones, incontinence, prostate disorder) Yes No Please specify which condition from the list and explain/give details: Integumentary*(skin, acne, psoriasis) Yes No Please specify which condition from the list and explain/give details: Lymphatic/Hematologic*(anemia, bleeding problems) Yes No Please specify which condition from the list and explain/give details: Neurological*(headaches, migraines, seizures, Bell’s Palsy) Yes No Please specify which condition from the list and explain/give details: Psychiatric*(anxiety, depression, ADD, Alzheimers) Yes No Please specify which condition from the list and explain/give details: Respiratory*(asthma, chronic bronchitis, emphysema) Yes No Please specify which condition from the list and explain/give details: Vascular/Cardiovascular*(elevated cholesterol, heart attack, Heart pain, high blood pressure, stroke, vascular disease) Yes No Please specify which condition from the list and explain/give details: Females*Are you pregnant or nursing? Yes No If you answered YES to any of the above or have a condition not listed, please explain and list medications:Patient’s Signature*Date* MM slash DD slash YYYY
*Closed daily from 1pm - 2pm for lunch
For medical emergencies after hours, please contact Omni Eye Services at (770) 996-6664.