MEDICATIONS/VITAMINS: Q I Will Provide a List Q I Have a List Today Q Listed Below Q None

PATIENT HISTORY

REASON FOR EXAM: q Eye Health Concern q Blur q Floaters q Headaches q Night Vision q Glasses q Contact Lenses q Other: ______

MEDICATIONS/VITAMINS: q I will provide a list q I have a list today q Listed below q None

______

REVIEW OF SYSTEMS: Please circle any conditions that apply or check this box èè q No medical issues

CONSTITUTION: Cancer, Fatigue, Disability, Weight gain/loss, Other______q None

ENT: Sinusitis, Laryngitis, Dry mouth, Hearing loss, Other______q None

NEURO: Epilepsy, Brain tumor, Migraine, MS, Stroke/CVA, Cerebral palsy, Other______q None

PSYCHIATRIC: Attention deficit, Depression, Anxiety, Bipolar, Other______q None

CARDIOVASCULAR: Heart disease, Hypertension, Vascular disease, Other______q None

RESPIRATORY: Asthma, Bronchitis, COPD, Emphysema, Sleep apnea, Other______q None

GI: Ulcer, Acid reflux, Colitis, Crohn’s, Celiac, Other______q None

GU: Prostate cancer, Benign prostate hypertrophy, Nursing, Herpes/Chlamydia, Other______q None

MUSC/SKEL: Rheumatoid arthritis, Osteoarthritis, Osteoporosis, Gout, MD, Other______q None

SKIN: Eczema, Psoriasis, Rosacea, Cold sores, Shingles, Other______q None

ENDOCRINE: Diabetes (Type 1/Type 2), Thyroid, Hormone dysfunction, Other______q None

BLOOD/LYMPH: High cholesterol, Anemia, Ulcer, Large-volume blood loss, Other______q None

ALLERGY/IMMUNE: Sjogren’s Syndrome, Auto-immune disorder______q None

§ ENVIRONMENTAL: Seasonal, Dust/Molds, Pets, Latex, Food, Other______q None

§ DRUG: Penicillin, Sulfa, Opiods, Other______q None

EYE HISTORY: Eye surgery, Cataract surgery, Amblyopia, Eye injury, Glaucoma suspect, Glaucoma, Strabismus, Macular degeneration, Keratoconus, Cataract, Retinal detachment, Other______q None

FAMILY EYE HISTORY: Cataract, Amblyopia, Retinal detachment, Glaucoma suspect, Strabismus, Keratoconus, Other______q None

Macular Degeneration q No q Yes If yes, who? ______

Glaucoma q No q Yes If yes, who? ______

FAMILY MEDICAL HISTORY:

Cancer, Hypertension, Cardiovascular, Thyroid, Stroke, Other______q None

Diabetes q No q Yes If yes, who? ______

SOCIAL HISTORY: Alcohol use: q Yes ______/week q No

Tobacco use: q Yes ______/day q No (q Never smoked q Former smoker)

CONTACT LENSES: q Current wearer q Occasional wearer q Interested in wearing contacts

LASIK OR OTHER REFRACTIVE SURGERY:

q Yes, I am interested in learning more about Lasik surgery. Please send me information by q Email q Mail q I have already had LASIK/Refractive surgery

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