Eye Care Professional Associates

Medical History Form

Name*

First Last

Today's Date*

Home Phone*

Cell Phone

Please select one:

Employed
Retired
Student

Date of Birth*

SSN#*

Gender

Male
Female

Date of last eye exam:

Age

Please select one:

Single
Married

Email

If minor, name of responsible party

Relationship to minor

Primary Physician

Physician Phone

Last Medical Exam Date

Are you pregnant or nursing?*

Yes
No

List all major surgeries, injuries, and/or hospitalizations you have had:

Do you have any allergies to medications? If yes, explain:

List any medications you currently take, including dosage and frequency:

Which pharmacy do you currently use? Please include name and location:

Please check any of the following you have had, now or in the past:

If other, please list:

Do you wear glasses

No
Yes

If yes, how old is your present pair of lenses?

Do you wear contacts?

Yes
No

If yes, how old is your present pair of contacts?

Type of contact lenses

Rigid
Soft
Other

Are they comfortable?

First Choice
Second Choice
Third Choice

Reason for today's visit:

Family History

Please note any family history (parents, grandparents, siblings, children, living or deceased) for the following disease/condition

Social History

This information is strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.

Yes I prefer to discuss the above directly with the doctor.

Yes
No

Do you drive?

Yes
No

If yes, do you have difficulty driving? If yes, please describe.

Smoking status

Never smoker
Current smoker
Former smoker

If current smoker, type/amount/how long:

Do you drink alcohol?

Yes
No

If yes, type/amount/how long:

Do you use illegal drugs?

Yes
No

If yes, type/amount/how long:

Are you sexually active?

If yes, are you currently active with:

One partner
Multiple partners

Review of Systems

Do you currently have, or have you ever had, any problems in the following areas:

Eyes (check all that apply)

Constitutional (check all that apply)

Fever/Chills
Unexplained weight loss/gain

Ear, Nose, Throat, Mouth (check all that apply)

Stuffy Nose
Ear Ache
Cough
Dry Mouth

Cardiovascular (check all that apply)

High Blood Pressure
Rapid Heart Beat

Hematologic/Lymphatic (check all that apply)

Bleeding
Anemia

Gastrointestinal (check all that apply)

Upset Stomach
Diarrhea
Constipation

Genitourinary (check all that apply)

Burning on urination
Urinary frequency
Incontinence

Musculoskeletal (check all that apply)

Joint pains
Stiffness
Arthritis
Rheumatoid arthritis

Integumentary (check all that apply)

Rash
Changing Moles

Neurological (check all that apply)

Headache/Migraine
Seizure
Stroke
Paralysis

Psychiatric (check all that apply)

Anxiety
Depression
Insomnia

Endocrine (check all that apply)

Diabetes
Hyperthyroidism
Hypothyroidism

Allergies/Immunologic (check all that apply)

Allergies
Hay Fever
Hives

If you answered YES to any of the above or have a condition not listed, please explain & list medications: