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.
________________________________________
________________________________________
________________________________________
Glare/light sensation……….………
________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
________________________________________
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Post-nasal drip…………………….
________________________________________
________________________________________
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………………………………….
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Blood problems/bleeding disorder………….
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Sickle cell anemia……….…………
____________________________________________
____________________________________________
____________________________________________
____________________________________________
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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
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
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
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