Medical Vision History

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    STEP 1: Vision History

    Do you now or have you ever had any of the following eye conditions?

    Blurred Vision:
    Itching:
    Tearing:
    Diabetic Retinopathy:
    Eyestrain:
    Eye Pain:
    Wear Glasses:
    Wear Contacts:
    Blindness:
    Dry Eyes:
    Crossed Eyes:
    Lazy Eye/Amblyopia:
    Eye Injury:
    Eye Operation:
    Flashes/Floaters:
    Cataracts:
    Glaucoma:
    Diabetes:
    Detachment:
    Macular Degeneration:
    Frequent Eye Infections:
    Discharge:
    Iritis or Uveitis:
    Poor Night Vision:
    Night Glare:
    Redness:
    Double Vision:
    Burning:
    Sensitivity to Eye Meds:
    Severe Sensitivity to Light:
    Eye Disease:
    Other:

    If you selected 'Yes' to any of the conditions, please explain


    Please describe any eye injuries or eye surgeries

    STEP 2: Review of Systems

    Do you have now or have you ever had any of the following medical conditions?

    Development Delays:
    Fatigue Syndrome:
    Hearing Loss:
    Sinusitus:
    Dry Mouth:
    Laryingitis:
    Multiple Sclerosis:
    Epilepsy:
    Cerebral Palsy:
    Tumors:
    Stroke:
    CVA:
    Migraines:
    Autism Spectrum Disorder:
    Depression:
    Attention Deficit Disorder:
    Anxiety Disorder:
    Bipolar Disorder:
    Hypertension:
    Stroke:
    Vascular Disease:
    Congestive Heart Failure:
    Cigarette Smoker:
    Bronchitis:
    COPD:
    Sleep Apnea:
    Crohns:
    Colitis:
    Celiac Disease:
    Ulcer:
    Acid Reflux:
    Prostate Disease:
    STD-Herpetic:
    Chlamydia:
    Benign Prostate Hypertrophy:
    Arthritis:
    Osteoarthritis:
    Fibromyalgia:
    Muscular Dystrophy:
    Ankylosing Spondylitis:
    Osteoporosis:
    Gout:
    Eczema:
    Rosacea:
    Headaches:
    Psoriasis:
    Herpes Simplex:
    Cold Sores:
    Herpes Zoster:
    Shingles:
    Type 1/2 Diabetes:
    Hormonal Dysfunction:
    Anemia:
    Blood Loss:
    Ulcer:
    Rheumatoid Arthritis:
    Lupus:
    Sjogrens:
    Skin Problems:
    Allergies:
    Asthma:
    Emphysema:
    Heart Disease:
    Kidney Disease:
    High Cholesterol:
    Cancer:
    Currently Pregnant:
    Currently Nursing:
    Other:
    If you selected 'Yes' to any of the conditions, please explain

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    STEP 3: Medication

    Please list medications of any kind that you are currently taking and the dosage

    Please list any known allergies or sensitivities to any medication and reaction

    STEP 4: Family History

    Cancer

    Cataracts

    Glaucoma

    Other


    Macular Degeneration

    Crossed Eyes


    Thyroid Issues

    High Blood Pressure

    Diabetes

    STEP 5: Health Habits

    NOTE: This information is kept strictly confidential

    Do you smoke or use tobacco products?

    Do you drink alcohol?

    Do you use any kind of illegal drugs?

    Have you ever been infected with Gonorrhea?

    Have you ever been infected with Hepatitis?

    Have you ever been infected with HIV?

    Have you ever been infected with Syphilis?

    Please indicate hobbies and interests

    FINAL STEP: Signature

    Patient Name *

    Date of Birth *

    Guardian Name