Patient Medical History Form

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Hodges Woodall Optometry, PC
814 E Washington St • Greencastle, Indiana 46135
Patient Medical History Form
Today’s Date: ______ /______ /______
Ms.
Mrs.
Mr.
Dr.
Gender:
M
F
Marital Status:
Single
Married
Widowed
Name: ________________________________________________ Date of Birth: _____ /_____ /_____ Age:_____
(Last)
(First)
(Middle I.)
Address: _______________________________________ City: _____________________ State: _____ Zip: _______
Phone/Cell: ____________________________________ Email Address: ___________________________________
Vision Insurance:____________________ Employer:_____________________ School/Grade: __________________
Parent/Legal Guardian: _______________________________________________ Date of Birth: ____ /____ /____
(If Applicable)
(Last)
(First)
(Middle I.)
Date of Last Eye Exam Date: ___________________ Name/location of eye doctor: __________________________
Date of Last Medical Exam: ____________________ Name/location of medical doctor: ______________________
Medical History
List all current medications, including eye drops and non-prescription medications: ________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
List all allergies (medication, food, seasonal allergies, latex, etc…): _______________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
List all major surgeries, including eye surgeries: _______________________________________________________
________________________________________________________________________________________________
Are you pregnant or nursing?
Yes
No
Do you smoke?
Yes
No
Do you drink?
Yes
No
Ocular History
Do you wear glasses?
Yes
No
If yes, how old is your current pair? _______________________
Do you wear contacts?
Yes
No
If no, are you interested in contacts today?
Yes
No
How many hours do you wear them each day?
< 6
6 - 12
12 +
What type of contact lens solution do you use?
BioTrue
Opti-Free
Renu
ClearCare
Generic
?
Check if you (the patient) or a family member (parent, grandparent, sibling, child) have had any of the following:
DISEASE
YOU
FAMILY
NO
DON’T KNOW
If family, what relationship to you?
Crossed or “lazy eye”:
_____________________________________
Blindness:
_____________________________________
Cataract:
_____________________________________
Glaucoma:
_____________________________________
Macular degeneration:
_____________________________________
Retinal detachment:
_____________________________________
Arthritis:
_____________________________________
Cancer:
_____________________________________
Diabetes:
_____________________________________
Heart Disease:
_____________________________________
High blood pressure:
_____________________________________
Kidney Disease:
_____________________________________
Lupus:
_____________________________________
Thyroid Disease:
_____________________________________
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