Patient History Form
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2Palos Verdes Family Vision Optometry
Patient History Form
Patient Name:
__ Date of Birth:
Date of last vision examination (if elsewhere):
Do you have any specific questions for your doctor today?
Contact Lens History:
If you are not a contact lens wearer, are you interested in trying contacts today?
Yes
No
Do you currently wear contact lenses?
Yes
No
Hours per day:
Days per week:
Brand or prescription you are currently wearing?
Today’s wear time:
Solution:
If not wearing contacts now, have you tried them in the past?
Yes
No
Reason for stopping?
Glasses History:
Are you planning to get new eyeglasses today?
Yes
No
Do you currently wear glasses?
Yes
No
Part-time
Full-time
Distance
Near
Glasses being worn now:
Single Vision
Bifocals
Progressive
Trifocals
Do you wear sunglasses?
Yes
No
Are your sunglasses your most recent prescription?
Yes
No
Are you interested in learning more about Laser Vision Correction?
Yes
No
Special Eyewear Needs:
Computer (special prescriptions, anti-glare tints or coatings)
Safety Glasses (gardening, woodworking, welding)
Occupational (mechanics, plumbers, pilots)
Sports / Hobbies (racket sports, motorcycle)
Social History:
On average, how many hours do you spend on the computer each day? __________________________
Do you have any hobbies and/or special interests?
Use of Alcohol:
None
Social use only
1-2 drinks daily
Above average use
Alcohol dependent
Use of Tobacco:
None
Former smoker
Light smoker
Average smoker
Heavy smoker
Chew
Use of Recreational Drugs:
None
Type & Frequency:
Sexually Transmitted Disease:
None
Yes
HIV Positive
Current Medications
1.
for
6.
for
2.
for
7.
for
3.
for
8.
for
4.
for
9.
for
5.
for
10.
for
Ocular Medications (including over-the-counter meds/drops):
Drug Allergies:
Yes
No
Please List:
OVER>>>
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