Health History Form

Health History Form

Health History Form

Health History Form

Health History Form

Please choose Yes or No for each that applies to you and fill in essential information.

Wear glasses

Wear contact lenses

Wear protective sun wear

Blurry vision at distance

Blurry vision at near

Frequent headaches

Eye itches or burn

Eyes feel dry

Glare at night

See floaters

See flashes of light

See double

Past Ocular History
Glaucoma


Cataract

Macular degeneration

Diabetic eye disease

Trauma

Retinal detachment

Lazy Eye

Color vision deficiency

Eye turn (Strabismus)

Laser treatments

Eye Surgery

Other

Family Ocular History
Glaucoma


Cataract

Cataract

Macular degeneration

Retinal Detachment

Other

Social History
Please list how many packs/day and years you have been smoking.

Please list how many packs/day and years you have been drinking.

Cancer
If no, leave blank. If yes, type:

Constitutional
Fever


​​​​​​​Fatigue

​​​​​Recent weight change

Migraines

Other

Cardiovascular
High blood pressure


Heart attack

Carotid artery disease

Other

Endocrine
Thyroid

If you do not have Diabetes, please leave blank. If yes, list how many years and your last blood sugar.

Other

Gastrointestinal
Hepatitis


Inflamed bowel disease

Other

Ear, Nose & Throat
Hearing impairment


Sinus

Other

Hematologic / Lymphatic
Anemia


Sickle cell

High Cholesterol

Abnormal bleeding

Other

Skin
Rash


Growth/Tumors

Other

Neurological
Stroke


Seizures

Multiple sclerosis

Other

Respiratory
Asthma


Emphysema

Shortness of Breath

Cough

Bronchitis

Pneumonia

Tuberculosis

Other

Genitourinary
Prostate


Kidney

Pregnant

Other

Immunologic
Immune Deficiency


Lupus

Sjogren's

Other

Musculoskeletal
Rheumatoid arthritis


Joint pain

Marfan's

Ankylosing spondylitis

Other

Psychiatric
Alzheimer's


Anxiety

Depression

Dementia

Schizophrenia

Other

Surgery or Hospitalization (Reason and Date)