Patient Medical History Form
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1PATIENT MEDICAL HISTORY FORM
(To be completed by Patient)
Name
Date
Ocular History
Eyes/Review of Systems
Complaints
NO
YES
Complaints
NO
YES
o
o
o
o
Dry Eyes
Loss of Vision
o
o
o
o
Retinal Detachment
Redness
o
o
o
o
Cataracts
Tearing
o
o
o
o
Glaucoma
Burning
o
o
o
o
Eye Injury
Discharge
o
o
Other
Diplopia (Double vision)
Medical History
Please list systemic illnesses, previous surgeries (including eye), and/or hospitalizations
Date
Review of Symptoms
NO
YES
NO
YES
Constitutional
Pertinent = 1 Sys
Musculoskeletal
o
o
o
o
Fever
Reviewed
Arthritis
o
o
o
o
Weight Loss
Muscular Dystrophy
Extended = 2-9
Cardiovascular
Sys Reviewed
Neurologic
o
o
o
o
Chest Pain
Strokes
Complete = 10+
o
o
o
o
Heart Disease
Bell's Palsy
Sys Reviewed
o
o
Respiratory
Neurologic Illness
o
o
Asthma
Psychiatric
o
o
o
o
Emphysema
Depression
o
o
Gastrointestinal
Anxiety
o
o
GI Bleeding
Endocrine
o
o
Integumentary
Thyroid Disease
o
o
Skin Cancers
Heme-Lymph
o
o
o
o
Previous Skin Peels
Hepatitis
Allergy/Immune
Other Systemic Illness
o
o
HIV
Other
Obstretical
o
o
Are you Pregnant?
Social History
Alcohol Intake Per Day
(including wine, beer, mixed drinks)
Smoker
PPD
Years
Current Occupation
Household
Lives Alone
Lives with Family
Other
Family Medical History (Do any members of your family have the following medical and/or ocular conditions?)
Medical
NO
YES
Ocular
NO
YES
o
o
o
o
Diabetes
Ptosis (Droopy Lid)
o
o
o
o
Cancer
Tear Duct Blockage
o
o
Heart Disease
Other
o
o
Thyroid Disease
Med History Form_0812
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