Patient Medical History Form
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1PATIENT MEDICAL HISTORY FORM FOR ALBEMARLE EYE CENTER
NAME:______________________________________
SEX:___________ DATE OF BIRTH:____________
DATE:_____________________
PRIMARY CARE PHYSICIAN: _____________________________
Please fill out the following: If "YES" please explain further and/or give date.
YES
NO
YES
NO
CURRENT EYE COMPLAINTS
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Asthma
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Loss of Vision
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Emphysema
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Blurred Vision
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Positive TB Test
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Double Vision
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Ulcer
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Mucous Discharge
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Hepatitis
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Redness
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Kidney/Bladder Problems
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Sandy or gritty feeling
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HIV/Aids
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Itching, burning, tearing
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Arthritis
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Glare Problem
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Migraine Headaches
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Eye Pain
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Headaches
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Floaters
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Cancer/Type:_______________
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Flashes
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Nervous Disorders
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Other:___________________
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Seasonal Allergies
PAST PATIENT MEDICAL HISTORY
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Sickle Cell
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Eye Diseases
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Cholesterol____________________
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Diabetes
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Other:_____________________
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Thyroid Disease
FAMILY HISTORY
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Heart Disease, Heart Attacks
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Eye problems, Explain________
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High Blood Pressure
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Diabetes
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Other:___________________
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Heart Problems
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List any Previous Surgeries
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Glaucoma
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)
Other:_____________________
SOCIAL HISTORY
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Do You Smoke?
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Do You Drink Alcohol?
CURRENT CONDITIONS (ROS)
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Do You Drive?
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Diabetes
LIST MEDICATIONS YOU ARE CURRENTLY TAKING
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)
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Thyroid Problems
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Anemia
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)
Sinus problems
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High Blood Pressure
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)
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Heart Disease
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)
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Acid Reflux
LIST MEDICATIONS YOU ARE ALLERGIC TO
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)
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Shortness of Breath
(Dr. Observation) M.S. ________________________
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