mime-version: 1.0 content-location: file:///C:/65572350/Pt.HistoryFormwp.htm content-transfer-encoding: quoted-printable content-type: text/html; charset="us-ascii" WINAMAC EYE ASSOCIATES

PATIENT  HISTORY<= span style=3D'font-size:12.0pt;mso-bidi-font-size:10.0pt'>  FORM

&n= bsp;

Name (incl. MI): ________________________________________ Birth Date:________________ Age:_____

Address:________________= __________________________________________________________________

Home Ph._____________________W= ork Ph._____________________Spouse or Parent:__________________

Occupation or Yr. In School: ____________________ Employer: ____________________________________

When was your last eye exam?___= ________WHERE was your last eye exam?___________________________

 

Do you want new glasses today?   &n= bsp;             Y   N         Do you have a backup pair of glasses?              Y=    N

Are you interested in new sunglasses? &nb= sp;       Y   N         Do you need safety glasses?           &n= bsp;           &nbs= p;      Y   N

Do you wear contact lenses?   =             &n= bsp;       Y   N         Do you need new/more contact lenses?             Y   N

If not, are you interested in contact lenses?=   Y   N         Are you interested in LASIK surgery? &nbs= p;             Y   N

Who is your family doctor?____= ___________________Your S.S. No. _________________________________

 

FAMILY HISTORY:  Has anyone in your family ever had the following:

   &nb= sp;    Glaucoma        = Y   N         High blood pressure    &nbs= p; Y   N

      = Diabetes        =    Y   N         Any eye disease            Y   N   If so: _____________________________________

 

PERSONAL HISTORY:   

How old were you when you first started to wear glasses? _= ____yrs.          Do you smoke?      Y   N

How much of the time do you wear your glasses?     All the time___=    Reading only___   Driving only___

Have YOU ever had any proble= ms in any of the following areas:

   &nb= sp;    Eye injury        =         =     Y   N         Floaters in your vision   Y   N               Glaucoma        =       Y   N

      Eye surger= y        =           Y   N         Head injury      =         =     Y   N               Other eye = disease   Y   N

      Diabetes        =            =     Y   N         Thyroid        =             =     Y   N               Heart         =              Y   N

      High blood pressure      Y   N         Endocrine/ho= rmone  &n= bsp;    Y   N               Sinus         =              Y   N

      Ear, nose,= or throat       Y   N         Nervous system            Y   N               Stomach/in= testinal   Y   N

      Lungs/brea= thing            Y   N         Psychological system    Y   N               Kidney/bla= dder  &n= bsp;    Y   N

      Skin probl= ems              Y   N         Muscle or bone            Y   N               Cancer        =            Y   N

     

When was your blood pressure last checked? ______________What was it? ______________________     

When was your last physical?_________ Results? _____= ______________________________________

IF you have diabetes, at what age were you diagnosed with diabetes? _________= yrs. of age

 

Do you have any aller= gies?   Y     N     If so, to what<= span class=3DGramE>:_______________________________________________  

____________________________________________________________________= ______________________

Do you have any other general health problems? ________________________________________________

____________________________________________________________________= ______________________

 

Are you taking any medications?      Y     N           If so, please li= st what you take and what conditions they’re

taken for (include over-the-counter and alternative medicines): ____________________________________________

____________________________________________________________________= ______________________

____________________________________________________________________= ______________________

Do you use any eye drops or any kind of medicine for the eyes? _____ I= f so, what:________________________

____________________________________________________________________= ______________________

 

What brings you in to see the doctor today?_________= ______________________________________________

____________________________________________________________________= ______________________

____________________________________________________________________= ______________________