General Information

Patient Name *

Date *

Family Physician *

Physician's Phone *

Do you have any problems in the following areas? If yes, provide information.

Ears, nose, mouth, throat *

Yes
No

If yes, explain the problem:

Respiratory (lungs, breathing) *

Yes
No

If yes, explain the problem:

Cardiovascular (heart/blood vessels) *

Yes
No

If yes, explain the problem:

Gastrointestinal (stomach/intestines) *

Yes
No

If yes, explain the problem:

Genitourinary (genitals/kidney/bladder) *

Yes
No

If yes, explain the problem:

Musculoskeletal (muscle pain, joint pain) *

Yes
No

If yes, explain the problem:

Integumentary (skin and/or breast) *

Yes
No

If yes, explain the problem:

Neurological (nervous system) *

Yes
No

If yes, explain the problem:

Endocrine (thyroid, adrenal, pituitary) *

Yes
No

If yes, explain the problem:

Hematologic (blood) *

Yes
No

If yes, explain the problem:

Lymphatic (lymph nodes) *

Yes
No

If yes, explain the problem:

Allergies (seasonal, foods, hay fever) *

Yes
No

If yes, explain the problem:

Cataracts *

Yes
No

If yes, explain the problem:

Glaucoma *

Yes
No

If yes, explain the problem:

Retinal Disease *

Yes
No

If yes, explain the problem:

Macular Degeneration *

Yes
No

If yes, explain the problem:

Eyelids *

Yes
No

If yes, explain the problem:

Crossed eyes, lazy eye, drooping eyelid, etc. *

Yes
No

If yes, explain the problem:

Do you see an Optometrist for routine eye exams? *

Yes
No

If yes, whom do you see?

When was your last eye exam? *

Do you wear glasses? *

Yes
No

If yes, how old are your glasses?

Do you have allergies to any medications? *

Yes
No

If yes, please list medications:

Do you have an allergy to LATEX? *

Yes
No

Have you ever been told you have or had MRSA (Methicillin-resistant Staphylococcus aureus)? *

Yes
No

Are you currently taking any medication? *

Yes
No

If yes, please list medications:

List any surgeries you have had:

List condition(s) you are being treated for:

Family History

If any member of you family (blood relative other than yourself) have or have had any of the following diseases, please fill in the appropriate spaces.

Blindness *

Yes
No

If yes, relationship to patient:

Cataract *

Yes
No

If yes, relationship to patient:

Glaucoma *

Yes
No

If yes, relationship to patient:

Macular Degeneration *

Yes
No

If yes, relationship to patient:

Retinal Disease *

Yes
No

If yes, relationship to patient:

Rheumatoid Arthritis *

Yes
No

If yes, relationship to patient:

Cancer *

Yes
No

If yes, relationship to patient:

Diabetes *

Yes
No

If yes, relationship to patient:

Heart Attack *

Yes
No

If yes, relationship to patient:

Hypertension *

Yes
No

If yes, relationship to patient:

Kidney Disease *

Yes
No

If yes, relationship to patient:

Thyroid Disease *

Yes
No

If yes, relationship to patient:

Stroke *

Yes
No

If yes, relationship to patient:

Tuberculosis *

Yes
No

If yes, relationship to patient:

Other (explain):

Social History

Do you drink alcohol? *

Yes
No

If yes, how much per day?

Do you smoke? *

Yes
No

If yes, how much per day?

Have you ever had a blood transfusion? *

Yes
No