New Adult Health History

First Name: *

Last Name: *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Work Phone:

Home/Cell Phone:

Email:

Date of Birth:

Occupation:

Employer:

Date of Last Eye Exam:

Primary Vision Insurance:

Secondary Vision Insurance:

Primary Medical Insurance:

Secondary Medical Insurance:

Other:

Name of person who referred you:

MEDICAL HISTORY

HAVE YOU HAD ANY OF THE FOLLOWING HEALTH PROBLEMS?

GastrointestinalYesNoNot Sure

Ears/Nose/ThroatYesNoNot Sure

CardiovascularYesNoNot Sure

RespiratoryYesNoNot Sure

High Blood PressureYesNoNot Sure

NeurologicalYesNoNot Sure

UrinaryYesNoNot Sure

Muscles/BonesYesNoNot Sure

SkinYesNoNot Sure

EyesYesNoNot Sure

EndocrineYesNoNot Sure

Blood/LymphYesNoNot Sure

Allergic/ImmunologicalYesNoNot Sure

HeadachesYesNoNot Sure

MentalYesNoNot Sure

List your medications followed by what they are for (ex. Insulin/Diabetes). Medication / Purpose:

Are you diabetic?YesNo

If yes, year of diagnosis:

Are you allergic to any medication?YesNo

Medications I am allergic too:

Name of Primary Care Physician:

Date of last visit:

List any surgeries:

FAMILY HISTORY

DOES ANY OF YOUR IMMEDIATE FAMILY HAVE ANY OF THESE CONDITIONS?

High Blood PressureYesNo

Who?

DiabetesYesNo

Who?

GlaucomaYesNo

Who?

Macular DegenerationYesNo

Who?

Retinal DetachmentYesNo

Who?

CataractsYesNo

Who?

PERSONAL EYE INFORMATION

Have you had any eye surgeries, injuries or serious conditions?YesNo

If yes, please describe:

If you checked anything above, are your symptoms worse:

In the morningLater in the day/eveningSame all day long

Do you ever wear (check all that apply)?

Prescription GlassesComputer GlassesPrescription SunglassesNon Prescription SunglassesSoft Contact LensesHard (Gas-permeable) contact lensesNon Prescription Reading Glasses

Tell us why you are here today (check all that apply):

New GlassesNew Glasses (if there is a change in prescription)New ContactsNew Contacts (possibly but need more information first)Eye Health problemEye Comfort problemAcademic problemOther

If other please specify:

Do you use a computer?YesNo

Number of hours per day?

Are there any times when you wish your vision was better?YesNo

If yes, please describe below:

Is there anything we forgot to ask? Please tell us anything you would like us to know about your visit so that we can better serve you:

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How did you hear about our office?

MEDICAL HISTORY

HAVE YOU HAD ANY OF THE FOLLOWING HEALTH PROBLEMS?

FAMILY HISTORY

DOES ANY OF YOUR IMMEDIATE FAMILY HAVE ANY OF THESE CONDITIONS?

PERSONAL EYE INFORMATION

Have you had any of these symptoms in the last week (check all that apply)?

If you checked anything above, are your symptoms worse:

Do you ever wear (check all that apply)?

Tell us why you are here today (check all that apply):