Patient Information Form - Ballard Vision Associates Page 2
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2EYE HEALTH HISTORY-CONTINUED
Are you interested in LASIK or other corrective surgical procedures? [ ] Yes [ ] No
Have you had LASIK or other corrective surgery? [ ] Yes [ ] No
If Yes, when?_______________________
How many total hours per day do you spend at a computer?_______
Please mark any of the following symptoms noticed after extended computer use:
[ ]Blurred Vision [ ]Eyestrain [ ]Dry Eyes [ ]Glare Sensitivity [ ]Headaches [ ]Neck/Backaches [ ]Distance Vision Blurred
Please mark any of the following eye diseases/conditions that apply to you OR your family(indicate which family members):
SELF
FAMILY
WHO?
SELF
FAMILY
WHO?
Blindness
[ ]
[ ]
__________________
Macular Degeneration
[ ]
[ ]
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Cataracts
[ ]
[ ]
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Retinal Detachment
[ ]
[ ]
_________________
Glaucoma
[ ]
[ ]
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Retinitis Pigmentosa
[ ]
[ ]
_________________
Keratoconus
[ ]
[ ]
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Other Eye Disease
[ ]
[ ]
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MEDICAL HISTORY
Date of Last Medical Exam: ___________________ Name of Primary Care Physician: __________________________________________________
Please mark any of the following health conditions that apply to you OR your family (indicate which family members):
oNONE
SELF
FAMILY
WHO?
SELF
FAMILY
WHO?
Acne Rosacea
[ ]
[ ]
_________________
Hay Fever/Allergies
[ ]
[ ]
_________________
AIDS/HIV(+)
[ ]
[ ]
_________________
Heart Condition
[ ]
[ ]
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Arthritis
[ ]
[ ]
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Hepatitis
[ ]
[ ]
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Artificial Joints
[ ]
[ ]
_________________
High Blood Pressure
[ ]
[ ]
_________________
Asthma
[ ]
[ ]
_________________
High Cholesterol
[ ]
[ ]
_________________
Bleeding Disorder
[ ]
[ ]
_________________
Kidney Disease
[ ]
[ ]
_________________
Cancer
[ ]
[ ]
_________________
Lupus
[ ]
[ ]
_________________
Depression
[ ]
[ ]
_________________
Migraine Headaches
[ ]
[ ]
_________________
Diabetes
[ ]
[ ]
_________________
Shingles
[ ]
[ ]
_________________
Emphysema
[ ]
[ ]
_________________
Skin Conditions
[ ]
[ ]
_________________
Epilepsy/Seizures
[ ]
[ ]
_________________
Stroke
[ ]
[ ]
_________________
Fibromyalgia
[ ]
[ ]
_________________
Thyroid Condition
[ ]
[ ]
_________________
Multiple Sclerosis
[ ]
[ ]
_________________
Muscular Dystrophy
[ ]
[ ]
_________________
If you have Diabetes: When were you diagnosed?___________________ What was your last A1C Level?___________________
How often do you check your blood glucose? ___________ Time of day checked:___________ Average glucose level: _____________
How long have you been treated for any other conditions listed above?____________________________________________________________________
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Please describe any major surgeries: __________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Are you pregnant? ______ If YES, how many months? ____ Are you nursing? _____ Gestational Diabetes? _____
Do you smoke? _____ If YES, how many years? ____ How many packs/day? ______
CURRENT MEDICATIONS:
ALLERGIES:
Include over-the-counter AND prescription drugs:
Include food AND drug allergies:
o NONE
o NONE
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THANK YOU!
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Parent category: Medical