Medical History

If you prefer, you can print a hard copy of this form and fax it to 561-981-8460..

Medical History

First Name

Last Name

Reason For Visit

State Eye Problem

Which Eye?

Right

Left

Both

Uncertain

When did you first notice this problem?

Have you been treated for this problem?

By Whom

When

Do you have records?

Yes

Ocular History

Surgery Type

Which Eye?

Right

Left

Both

Date of Surgery

Previous Eye Doctor

Clinic / Hospital

Date of Last Exam

Address

City

State

ZIP Code

Phone

Fax

Records

Yes

Medical History

Social History (This Entire Form is Kept Confidential)

Smoking / Tobacco

Yes (current)

Yes (desire to quit)

Former

Never

Alcohol (please describe type, frequency, and amount

Recreational Drugs (please describe type, frequency, and amount

Family Ocular History

Relative

Problem(s) (e.g glaucoma, macular degeneration, diabetes, etc)

Relative

Problem(s) (e.g glaucoma, macular degeneration, diabetes, etc)

Allergies

Allergy

Reaction(s) (e.g. hives, anaphylaxis, itching, etc)

Allergy

Reaction(s) (e.g. hives, anaphylaxis, itching, etc)

Medications

Eye Drops

Eye Drop Name	Dosage / Units	Frequency

Other Medications

Medication Name	Dosage / Units	Frequency

Review of Systems

Symptoms

	Yes	No
Sudden loss of vision
Sensitivity to light / glare
Blurry vision despite glasses
Itchy / red eyes?
Eye pain?
Dizziness?
Headaches?
Weight loss or gain?
Change in appetite?
Night sweats?
Fatigue?
Difficulty Sleeping?
Feel hotter than others?
Feel colder than others?
Non-healing skin/foot ulcers?
Dry skin?
Hair changes/ thinning?
Easy bruising or bleeding?
Seasonal allergies/hives?
Neck pain?
Neck lumps or goiter?
Difficulty swallowing?
Change in hearing?
Shortness of breath?
Frequent coughs/wheezing?
Voice changes?
Chest pains?
Palpitations?
Nausea?
Heartburn/reflux
Abdominal pain?
Other?