Salem Vision Center Medical History

Name

First Last

Date

Do you have any allergies to medications, dyes, foods, pollen, animals, etc.?

Yes
No

If yes, please list

List any medications you currently take (include over the counter, oral contraceptives, home remedies, vitamins, aspirin, etc.)

List any surgeries and/or hospitalizations

List any of the following that you have had: crossed eyes, drooping eyelid, protruding eyes, glaucoma, retinal disease, cataracts, eye infections or eye injury

Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions

Social History

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

Do you use tobacco products?

Yes
No
I prefer to speak to the doctor directly

If yes, type/amount/how long

Do you drink alcohol?

Yes
No
I prefer to speak to the doctor directly

If yes, type/amount/how long

Do you use illegal drugs?

Yes
No
I prefer to speak with the doctor

If yes, type/amount/how long

Have you ever been exposed or infected with

Gonorrhea
Hepatitis
HIV
Syphilis

Do you currently or have you ever had any difficulties with the following

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

Signature

Date