Please complete the following form as thoroughly as possible. The information in this confidential case history form is critical to the evaluation of your vision and health.Patient Name* Date* MM slash DD slash YYYY Patient Medical HistoryCurrent Medications (Rx or Over-the-Counter)(List name of medications: eye drops, vitamins, birth control pills, dosages, and frequency.)Allergies to Medications or Latex?* Yes No If so, what medications? Are you currently pregnant or nursing?* Yes No Have you ever been diagnosed or treated for any of the following health problems?Check all that applyConstitution Fatigue Fevers Unusual weight loss/gain Cancer Cardiovascular High blood pressure High cholesterol Stroke/CVA Heart disease Vascular disease Congestive heart failure Muscular/Skeletal Osteoarthritis Fibromyalgia Muscular dystrophy Ankylosing spondylitis Ear/Nose/Throat Hearing loss Sinusitis Throat infections Respiratory Asthma Bronchitis Emphysema Integumentary Eczema Rosacea Psoriasis Herpes simplex Herpes zoster Neurological Migraines Multiple sclerosis Epilepsy Cerebral palsy Tumor Autism spectrum disorder Gastrointestinal Crohn’s Disease Colitis Celiac Disease Endocrine Diabetes, type I Diabetes, type II Thyroid Psychiatric Depression Attention deficit Anxiety disorder Bipolar disorder Hematologic/Lymphatic Anemia Ulcer Genitourinary Kidney disease Prostate disease STD- herpes/chlamydia Allergy/Immune Environmental allergies Rheumatoid arthritis Lupus Sjogren’s syndrome Patient Eye HistoryDate of Last Eye Exam* By Whom?* Have you had any eye-related surgeries of any kind?* Yes No Explain* Have you ever experienced, been diagnosed or treated for any of the following?Check all that apply Blurry Vision Burning Cataracts Corneal Abrasions Crossed eye/Eye turn Double Vision Eye infections Eye Injury Flash of light Floater/spots Glaucoma Grittiness Headaches Iritis/Uveitis Itchiness Lazy Eye Macular Degeneration Occasional dryness Retinal Detachment Sunlight sensitivity Tearing Trouble seeing at night Uncomfortable glasses Other eye disorders Please list Do you use...Cigarettes or tobacco?* Yes No Alcohol?* Yes No Other substances?* Yes No HobbiesFamily Medical/Eye HistoryDo you have a family medical history of any of the following? (Please indicate which family member and if applicable maternal/paternal side in the space given)Check all that apply Cataracts Macular Degeneration Glaucoma Retinal Problems Diabetes (Type 1 or 2) High Blood Pressure Thyroid (High or Low) Cancer Other Significant Issues Please list medical condition and relationLifestyle QuestionsDo you...Check all that apply ...Use digital devices on a regular basis? ...think you might benefit from thinner, lighter lenses? ...prefer NOT to wear glasses at times? ...spend time outdoors? ...participate in vision-related sports or other activities? How many hours per day? How often? (hrs/wk) Please specifiy CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
