Welcome to our office.  By completing this history form,
 you will help us to serve you more efficiently. 
Should you have any questions concerning our professional services
 or office procedures, please ask.

                                                                                                                                                                      

GENERAL INFORMATION                                                                                                  Date:                                                      

Method of Payment:                Check / Cash / Credit Card                        Insurance                 Medi-Cal 

Mr           Mrs          Ms           Name                                                                                                                Date of Birth                                          

Sex  M         or F                                      Social security #                       /               /                               Age                                                         

Address                                                                                    City                                                         State             ZIP                                    

PO Box                                    Home Phone                                                                            Work Phone                                                           

Employer                                                                                 Occupation                                                                                             

E-mail:                                                                                     Spouse/Parent/Guardian (If apply)                                                                           

Emergency Contact                                                                 Phone                                                      Relationship                            

MEDICAL HISTORY                                                                                                                                        Last Eye Exam                                                                       

Do you wear Glasses?                               NO  /  YES                               If YES, How old are your lenses?                                                             

Do you wear Contact Lenses?  NO  /  YES                               If YES, How old is your present pair?                                      

Medical Doctor                                                                                                        Last Medical Exam                                                 

Do you have any allergies to Medications?  NO  /  YES            If YES, Explain:                                                                                      

List any medications you take (including oral contraceptives, Asprin, over the counter medications, vitamins, herbs, and home remedies):                                                                                                                                                                                                                                                                                                                                                                                                                                            

Have you had Refractive Surgery (Lasik, RK, etc.)?             NO  /  YES               Date:                                        Doctor:                                   

Are you currently pregnant or nursing?    NO  / YES

Have you had Cataract Surgery?    NO  /  YES          Right Eye Date                        Left Eye Date                          Doctor?                  

Please note any Family History (Parents, Grandparents, Siblings) for the following conditions:

Blindness                                                                                         

Crossed Eyes                                                                                   

Macular Degeneration                                                                       

Arthritis                                                                                            

Diabetes                                                                                           

High Blood Pressure                                                                          

Lupus                                                                                              

        No           Yes             Relationship

Glaucoma                                                                           

Retinal Disease                                                                   

Cancer                                                                              

Heart Disease                                                                    

Kidney Disease                                                                  

Thyroid Disease                                                                 

Other                                                                                      

 

Do you drive?          NO  /  YES              If YES, Do you have visual difficulties when driving?               NO / YES

If YES, please describe:                                                                                                                                                                                           

Do you use Tobacco products? NO  /  YES               If YES, Type / Amount / How Long:                                                       

Do you drink alcohol?                              NO  /  YES               If YES, Type / Amount / How Long:                                                       

Do you use illegal Drugs?                          NO  /  YES               If YES, Type / Amount / How Long:                                                       

Have you ever been exposed to or infected with:          Gonorrhea                           Hepatitis  HIV                          Syphilis

PLEASE TURN THIS FORM OVER AND COMPLETE SIDE TWO

What are your current visual needs that you would like to have addressed today?                                                                                                                                                                                                                                                                                                                    

Do you currently or have you ever had any problems in the following areas?

No    Yes    ?                                                                                           Explain / List Medications                                                      

                        Constitutional (fever, wt gain / loss)                                                                                                                        

                        Integumentary (skin)                                                                                                                                                              

                                NEUROLOGICAL

                        Headaches                                                                                                                                                                               

                        Migraines                                                                                                                                                                

                        Seizures                                                                                                                                                                                   

EYES

                        Amblyopia (lazy eye)                                                                                                                                                              

                        Strabismus (wandering eye)                                                                                                                                      

                        Blurred Vision                                                                                                                                                                         

                        Distorted Vision / Halos                                                                                                                                                          

                        Loss of Side Vision                                                                                                                                                  

                        Double Vision                                                                                                                                                                          

                        Dryness                                                                                                                                                                                   

                        Foreign Body Removal                                                                                                                                                            

                        Mucous Discharge                                                                                                                                                   

                        Redness                                                                                                                                                                                   

                        Sandy or Gritty Feeling                                                                                                                                                           

                        Itching                                                                                                                                                                                    

                        Burning                                                                                                                                                                                   

                        Foreign Body Sensation                                                                                                                                                           

                        Excess Tearing / Watering                                                                                                                                                      

                        Glare / Light Sensitivity                                                                                                                                                          

                        Eye Pain or Soreness                                                                                                                                                               

                        Chronic Infection of eye or lid                                                                                                                                

                        Sties or Chalazion                                                                                                                                                   

                        Flashes of light                                                                                                                                                                        

                        Floaters in vision                                                                                                                                                                    

                        Tired Eyes                                                                                                                                                                              

EARS, NOSE, MOUTH, THROAT

                        Allergies / Hayfever                                                                                                                                                

                        Sinus Congestion                                                                                                                                                                     

                        Runny Nose                                                                                                                                                                            

                        Post-Nasal Drip                                                                                                                                                                      

                        Chronic Cough                                                                                                                                                                        

                        Dry Throat / Mouth                                                                                                                                                

VASCULAR

                        Diabetes                                                                                                                                                                                  

                        Heart Pain                                                                                                                                                                              

                        High Blood Pressure                                                                                                                                                

                        Vascular Disease                                                                                                                                                                      

GASTROINTESTINAL

                        Diarrhea                                                                                                                                                                                  

                        Constipation                                                                                                                                                                           

BONES / JOINTS / MUSCLES            

                        Rheumatoid Arthritis                                                                                                                                                              

                        Muscle Pain                                                                                                                                                                            

                        Joint Pain                                                                                                                                                                               

LYMPHATIC / HEMATOLOGIC

                        Anemia                                                                                                                                                                                   

                        Bleeding Problems                                                                                                                                                   

                        Allergic / Immunologic                                                                                                                                                            

                        Thyroid / other glands                                                                                                                                                             

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