Fichman Eye Center

MEDICAL HISTORY FORM PAGE 1/2

Patient Name: ______Patient D.O.B: ___ / ___ / ______

Primary Care Physician’s Name:______PCP’s Phone #:______

Pharmacy Name:______Pharmacy Phone: ______

Pharmacy Address: ______

When was your last routine eye exam? ______

What’s the reason for your visit today? ______

MEDICAL STATUS AND HISTORY:

Do you take any medications? NO / YES Do you have any drug, food,

**If yes, please list below. Please include over-the-counter or environmental allergies? NO / YES

medications such as aspirin. **If yes please list below.

Medication Name / Dosage / Reason you take this med
Allergy / Reaction

REVIEW OF SYSTEMS:

Do you have a present/past history of the following conditions? / NO / YES / Explanation
Chronic Fever, weight loss/gain, fatigue?
Cardiovascular: (heart disease, hypertension, cholesterol)
Ear/Nose/Throat: (hearing loss, sinus problems, tinnitis, vertigo)
Respiratory: (asthma, COPD, shortness of breath, emphysema)
Gastrointestinal: (GERD, acid reflux, IBS, Hepatitis A, B, C)
Genitourinary: (kidney, dialysis, bladder, prostate, ovarian cancer)
Musculoskeletal: (arthritis, fibromyalsia, osteoporosis, Gout)
Integumentary: (psoriasis, eczema, rosacea, skin cancer)
Neurological: (Alzheimer's, seizures, headaches, stroke, sleep apnea)
Psychiatric: (depression, anxiety, bipolar disorder, ADD/ADHD)
Endocrine: (thyroid, diabetes, Grave's disease, Cushing's Syndrome)
Hematologic/Lymphatic: (anemia, sickle cell, blood disorder)
Allergic/Immunologic: (HIV/AIDS, Lupus, organ transplant)
Cancer:
Other:

Have you ever been treated for diabetes? NO / YES **If YES: Gestational, Type I, or Type II? ______

What year were you diagnosed?______Do you take insulin? NO / YES

Fichman Eye Center

MEDICAL HISTORY FORM PAGE 2/2

Patient Name: ______Patient D.O.B: ___ / ___ / ______

Have you ever been hospitalized or had surgery? NO / YES (If yes, please provide approximate year & type of surgery) ______

______

Do you have any past or recent exposure to any infectious diseases such as MRSA or shingles? NO / YES

FOR WOMEN ONLY: Are you pregnant? NO / YES Are you breast-feeding? NO / YES

OCULAR HISTORY: FAMILY HISTORY:

Disease / NO / YES / Relationship to patient
Glaucoma
Cataracts
Macular Degen.
Eye Injury
Retinal Disease
Blindness
Lazy Eye
Diabetes
Cancer
Heart Disease
Hypertension
Cholesterol
Kidney Disease
Stroke
Other

Have you ever had any of the Do any medical or eye diseases run in your family?

following eye diseases? **If yes, please provide details below.

Disease / NO / YES
Glaucoma
Cataracts
Macular Degeneration
Eye Injury
Retinal Disease
Blindness
Lazy Eye
Diabetic Retinopathy
Dry Eye Syndrome

Have you ever had any eye surgery or

Laser procedures? NO / YES

*If yes, please provide date and type

of procedure below:

______

______

______

REVIEWED: / DATE / Patient Initials / Doctor Signature
___/___/___
___/___/___
___/___/___

SOCIAL HISTORY:

Do you smoke? NO / YES Do you drink alcohol? NO / YES

*If yes, how much per day? ______*If yes, how much per day? ______

Do you have a history

of smoking? NO / YES