Vision Quest-- EyeCare & Surgery Center
EYE AND MEDICAL HISTORY-PAGE-1
Patient Name:
Date:
SOCIAL INFORMATION:
Do you smoke:
Yes
No
Packs Per Week:
Notes:
Do you drink alcohol:
Yes
No
Amount:
$
Do you use computer:
Yes
No
Hours per Day:
Notes:
Do you exersise:
Yes
No
Times Per Week:
Hours
Do you take nutrition supplements:
Yes
No
What do you take:
Current Occupation:
UnKnown
Employed-FullTime
Employed-PartTime
UnEmployed
Student
Retired
N/A
Disabled
HomeMaker
Hobbies:
MEDICAL AND FAMILY HISTORY/ REVIEW OF SYSTEMS:
Immediate
Immediate
Patient
Family
Patient
Family
Anemia:
Yes
No
Yes
No
Headaches:
Yes
No
Yes
No
Ashtma:
Yes
No
Yes
No
Hearing Problems:
Yes
No
Yes
No
AIDS:
Yes
No
Yes
No
Irregular Heart Beat:
Yes
No
Yes
No
Arthritis/Joint Pain:
Yes
No
Yes
No
Kidney Disease:
Yes
No
Yes
No
Bleeding Disorder:
Yes
No
Yes
No
Lupus:
Yes
No
Yes
No
Bladder Disease:
Yes
No
Yes
No
Migraines:
Yes
No
Yes
No
Congestive Heart Failure:
Yes
No
Yes
No
Positive HIV:
Yes
No
Yes
No
Chronic Cough:
Yes
No
Yes
No
Stroke:
Yes
No
Yes
No
Chronic Constipation:
Yes
No
Yes
No
Sinus/Allergies:
Yes
No
Yes
No
Chronic Diarrhea:
Yes
No
Yes
No
Seizure Disorder:
Yes
No
Yes
No
Cancer:
Yes
No
Yes
No
Tuberculosis:
Yes
No
Yes
No
Diabetes:
Yes
No
Yes
No
Thyroid Disease:
Yes
No
Yes
No
Dry Skin/Mouth:
Yes
No
Yes
No
Ulcer:
Yes
No
Yes
No
Depression:
Yes
No
Yes
No
Weight Loss/Gain:
Yes
No
Yes
No
Emphysema:
Yes
No
Yes
No
High Blood Pressure:
Yes
No
Yes
No
Heart Condition:
Yes
No
Yes
No
Technician/Doctor Notes:
OCULAR HISTORY:
Immediate
Immediate
Patient
Family
Patient
Amblyopia:
Yes
No
Yes
No
Do you wear glasses:
Yes
No
Cataracts:
Yes
No
Yes
No
Do you wear Contacts:
Yes
No
Glaucoma:
Yes
No
Yes
No
Eye Surgery:
Yes
No
Macular Degeneration:
Yes
No
Yes
No
Eye Injury:
Yes
No
Retinal Problems:
Yes
No
Yes
No
Relationship to Patient/ Notes:
MEDICAL HISTORY:
Sr.No.
List the last 10 years of prior surgeries:
List All current Medications
(Including non-prescription medications)
List All allergies to medications
1
2
3
4
5