Eye Health Solutions – Medical History – Patient Registration Forms

Medical History

Patient Name*

First Last

Today's Date*

Primary Care Physician:*

Other Physicians You See On A Regular Basis:*

Your Pharmacy:*

Location:*

Have you had any bad reactions to medications or nutritional supplements?*

Yes
No

If yes, explain:

Are you pregnant or nursing?

Yes
No

Have you had any of the following?*

Crossed Eye (strabismus)
Lazy Eye (amblyopia)
Keratoconus
Iritis / Uveitis
Cataracts
Glaucoma
Optic nerve disease
Retinal Disease
None

Eye injury?*

No
Yes

Which eye(s)?

Right
Left
Both

When:

Details:

Eye surgery or laser*

No
Yes

Which eye(s)?

Right
Left
Both

When:

Details:

List all major injuries, surgeries and/or hospitalizations you have had, not related to your eyes:*

Do you have any of these symptoms CURRENTLY?*

Blurry vision
Double vision
Floaters blocking vision
Itching
Red eyes or lids
None

Do you have any ONGOING problems in these areas?*

Have you been diagnosed with any of the following?*

List all major diagnoses NOT listed above:*

Family History

Parents, grandparents, and siblings with the following conditions:*

Crossed eyes (strabismus)
Glaucoma
Macular degeneration
Retinal detachment/disease
None

Social History

Do you drive?*

Yes
No

Do you smoke?*

Yes
No

Do you drink alcohol on a daily/weekly basis?*

Yes
No

If you have a list of medications, please give to front desk to make a copy.*

If not, list ALL medications you take (including oral contraceptives, aspirin, over the counter medications, alternative treatments, and nutritional supplements):