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Medical history form

CONFIDENTIAL MEDICAL HISTORY
Today’s Date __________________
NAME ________________________________________AGE_________ DATE OF BIRTH_____________________
Referring doctor_____________________________________________ Date of last physical exam _______________
Medical doctor (primary care physician)________________________ Date of last eye exam ____________________
Where do you have your glasses made?________________________ Name of optometrist______________________
Reason for evaluation: ______________________________________________________________________________
Do you currently have any problems in the following areas? If “yes”, provide a description and the doctor who treats
you for that problem (if there is one). If there are multiple choices on one line, please circle all that apply.
EXPLANATION AND TREATING DOCTOR
________________________________________
Fever………………………….…. ________________________________________
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Loss of vision……………………… ________________________________________
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Distorted vision (halos)…….……… ________________________________________
Double vision……………………… ________________________________________
Dryness, sandy, or gritty feeling….
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Redness…………………….……… ________________________________________
Itching, burning, or foreign body sensation. ________________________________________
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Glare/light sensation……….……… ________________________________________
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Post-nasal drip……………………. ________________________________________
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Cardiovascular (heart/blood vessel disease) ________________________________________
Heart attack………………………. ________________________________________
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Ulcer………………………………. ________________________________________
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Joint pain/arthritis…………………. ________________________________________
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Stroke……………………………… ________________________________________
Psychiatric…………………………………. ____________________________________________ Blood problems/bleeding disorder…………. ____________________________________________ Sickle cell anemia……….………… ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ HIV (+) or AIDS…………………………… ____________________________________________ Thyroid Disease………………………… ____________________________________________ MALE PATIENTS ONLY:
____________________________________________ Medication used (past or present): Circle all that apply Flomax (Tamulosin), Rapaflo (Silodosin), Hytrin (Terazosin), Cardura (Doxazosin), Jalyn PAST HISTORY
Please list any allergies to medications or eyedrops____________________________________________________________
Please list all major illnesses and injuries
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Please list any surgeries you have had-include eye surgery
_____________________________________________________________________________________________________
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FAMILY HISTORY
HOW ARE THEY RELATED TO YOU?
Blindness…………………………. __________________________________________________ Cataract……………………………. __________________________________________________ __________________________________________________ __________________________________________________ Diabetes…………………………… __________________________________________________ Heart disease………………………. __________________________________________________ __________________________________________________ Stroke……………………………… __________________________________________________ Cancer……………………………. __________________________________________________ Other………………………………. __________________________________________________ SOCIAL HISTORY
CURRENT MEDICATIONS-please list all
prescriptions, over-the-counter, medicines AND
EYEDROPS (including the dosage and frequency):
_______________________________________________
_______________________________________________
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Source: http://busackeye.com/documents/Medical_History_Form.pdf