Health History Form

Health History Form

Health History Form

Health History Form

Patient Full Name

Patient Date of Birth: Ex: 07/13/1969

Primary Care Physician

Date Last Seen by Primary Care Physician: Ex: 07/13/2018

Medical/Family History

Please list all your current medications (include over the counter, vitamins and herbal therapy)

List all major surgeries (Eye Surgery included)

List any allergic reactions to medications or eye drops

Please indicate if any of the conditions apply to you or a family member (blood relatives only)

Women - Are you pregnant?

Women - Are you breast feeding?

Ever had a blood transfusion?

Cataract?

Eye Turn?

Glaucoma?

Macular Degeneration?

Retinal Detachment?

Blindness?

Review of Systems

Please indicate below if you have any problems with the following conditions:

Allergic/Immunologic

Immunologic Ear, Nose, and Throat

Gastrointestinal

Skin Integumentary

Endocrine/Glands

Respiratory

Muscle/Skeletal

Genital/Urinary

Hematologic/Lymphatic

Neurological

General Health

Social

Psychiatric

Cardiovascular

Weight

Height

Alcohol Consumption

Smoked a day

How many years quit

Non-Prescription Drugs

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