Ocular Health History Sheet printable pdf download

Ocular Health History

Patient Name:

Date:

Email Address:

Phone No.

Address:

Job Position:

Employer:

Start Date:

Years:

Screen Time Hours per Day:

Distance from Screen:

Miles Driven per Day:

Day or Night:

Glare Problems while Driving: ¨ Yes

¨ No

Night Vision Problems: ¨ Yes

¨ No

Glasses: ¨ Yes

¨ No

Year Acquired:

Type: ¨ Full-time ¨ Occupational ¨ Reading ¨ Distance ¨ Bifocal ¨ Safety ¨ Athletics

Sunglasses: ¨ Yes

¨ No

Prescription: ¨ Yes

¨ No

Contacts: ¨ Yes

¨ No

Willing to Try Contacts: ¨ Yes

¨ No

Medications:

Allergies:

Pregnant: ¨ Yes

¨ No

Nursing: ¨ Yes

¨ No

Alcohol Use: ¨ Never

¨ Occasionally ¨ Monthly ¨ Weekly ¨ Daily ¨ 4+ per Day

Smoking: ¨ Never

¨ Occasionally ¨ 1 per Day ¨ 1 Pack per Day ¨ 2+ Packs per Day

Illegal Drug Use: ¨ Never

¨ Occasionally ¨ Monthly ¨ Weekly ¨ Daily

Exercise: ¨ Never

¨ Occasionally ¨ Weekly

¨ 2-3 Times per Week ¨ Daily

My History

My Family History

Amblyopia

¨ Yes

¨ No

Amblyopia

¨ Yes

¨ No

Blindness

¨ Yes

¨ No

Blindness

¨ Yes

¨ No

Blurred Vision

¨ Yes

¨ No

Blurred Vision

¨ Yes

¨ No

Burning Sensation

¨ Yes

¨ No

Burning Sensation

¨ Yes

¨ No

Cataracts

¨ Yes

¨ No

Cataracts

¨ Yes

¨ No

Color Blindness

¨ Yes

¨ No

Color Blindness

¨ Yes

¨ No

¨ Yes

¨ No

¨ Yes

¨ No

Diabetic Retinopathy

Distorted Vision

¨ Yes

¨ No

Distorted Vision

¨ Yes

¨ No

Dry Eyes

¨ Yes

¨ No

Dry Eyes

¨ Yes

¨ No

¨ Yes

¨ No

¨ Yes

¨ No

Epiphora

Glaucoma

¨ Yes

¨ No

Glaucoma

¨ Yes

¨ No

Headaches

¨ Yes

¨ No

Headaches

¨ Yes

¨ No

Infection

¨ Yes

¨ No

Infection

¨ Yes

¨ No

Injury

¨ Yes

¨ No

Injury

¨ Yes

¨ No

Itching

¨ Yes

¨ No

Itching

¨ Yes

¨ No

Light Sensitivity

¨ Yes

¨ No

Light Sensitivity

¨ Yes

¨ No

Loss of Vision

¨ Yes

¨ No

Loss of Vision

¨ Yes

¨ No

Mucous Discharge

¨ Yes

¨ No

Mucous Discharge

¨ Yes

¨ No

Redness

¨ Yes

¨ No

Redness

¨ Yes

¨ No

Retinal Detachment

¨ Yes

¨ No

Retinal Detachment

¨ Yes

¨ No

¨ Yes

¨ No

¨ Yes

¨ No

Strabismus

Swelling

¨ Yes

¨ No

Swelling

¨ Yes

¨ No

Tired/Sore

¨ Yes

¨ No

Tired/Sore

¨ Yes

¨ No

Ocular Health History Sheet

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