Ocular and Medical History Questionnaire Name* First Last Date of Birth MM slash DD slash YYYY AGEDate MM slash DD slash YYYY Email* Name of Family Doctor PhoneDate of last physical MM slash DD slash YYYY Name and Location of Pharmacy Pharmacy TelephoneEye Doctor’s Name Date of last Eye Exam MM slash DD slash YYYY Main reason for TODAY’S office visit?Blurred Vision at Distance Near Computer Past Ocular History - Please check all that apply Amblopia (Lazy Eye) Astigmatism Cataracts Corneal Disorder Diabetic Retinopathy Dry Eye Syndrome Glaucoma Hyperopia (Farsighted) Iritis / Uveitis Macular Degeneration Myopia (Near sighted) Retinal Detachment Ocular Surgeries - Please check all that apply Blepharoplasty (Lid Surgery) Cataract Surgery Corneal Transplant Glaucoma Surgery Laser Retinal Surgery Lasik Surgery Strabismus (Eye Muscle Surgery) Vitrectomy Yag Laser Capsulotomy Other Current Eye Medications Name and Dosage - Please List Review of Eye Systems - Please check all that apply Glaucoma Eye Pain Corneal Abrasion Eye Infection Cataracts Eye Injury Grit / SandyFeel Pus Macular Degeneration Spots / Floaters Red Bloodshot Discharge Detached Retina Peripheral Vision Loss Eyelids Swollen Burning Blindness Sensitivity to Light Dry Eye Itching Eye Diseases Poor Night Vision Excessive Tears Eye Surgery Loss of Central Vision Optical Life Style QuestionsDo you wear glasses for Distance, Reading Computer? Multifocal or a progressive Daily Hours on?ComputerLap TopIpad /KindleVideo GamesSmart PhoneDo you have a back-up pair of glasses or sunglasses? Do you currently have glasses with a Blue Filter Protection? Are you planning to fill your prescription in a New Frame , Current Frame or Sunglass Please list the type of Transitions, polarization or a clip on for UV Eye Protection you currently using Do you wear contact lenses? Yes No what type of lenses: Single Vision, Multifocal or Astigmatism How frequently do you change your contact lenses (Daily weekly, monthly, Yearly)? Have you worn them in the past? Yes No Age of your current contact lenses? Name of Disinfection system Are you interested in a contact lens exam Today? Yes No Would you like more information about contacts? Yes No Medical History QuestionaireOther Medical History - Please check all that apply Anemia Headache Liver Disease Arthritis Hearing Loss Lupus / Fibromyalgia Arrthymia Heart Attack Migraine Asthma Hepatitis A B C MS / Neurological Disease Cancer High Blood Pressure Pyschiatric Disorder Congestive Heart Failure High Cholestrol Rheumatoid Arthritis Lung / COPD HIV / AIDS / Herpes / STD Stroke Kidney Diease Thyroid Disease Type Diabetes type 1 2 When were you diagnosed Do you take insulin? What was your last A1C Last BS level at in am pm All Other Medications- Please List General Surgeries / Procedures- Please List AllergyReactionSeverity (Mild, Moderate, Severe) Please list any Vitamin Supplements you are taking include dosage Social History:Do you smoke? Yes No Have you ever smoked? Yes No how often and how many packs a day Do you use Alcohol? Yes No How much and how often Do you Drugs? Yes No which and how long Please list any blood relatives with any of the followingDiabetes Cancer Heart Disease Asthma / COPD / TB High Blood Pressure Glaucoma Thyroid Macular Degeneration Stroke Retinal Disease / Detachment Kidney Disease Blindness / Lazy Eye Lupus / Sjogrens’ Cataracts Review of Systems- Please check all that applyEars Nose and Throat Hard of Hearing Ringing in Ears Vertigo Constitutional Fatigue / Weakness Fever Weight Gain / Loss Gastrointestional Heartburn Nausea/ Vomiting Jaundice Psychiatric Anxeity / Depression Mood Swings Difficulty Sleeping Musculoskeletal Stiffness Arthritis Joint Pain Skin Rash / Sores Lesions Hives / Eczema Cardiovascular Chest Pain Irregular-Heart-Beat Fainting-Spells Dizziness Shortness of Breath Difficulty Laying Flat Respiratory Cough Congestion Wheezing Asthma Genitourary Pain / Difficulty Hx of Kidney Stones Pregnant Blood in Urine History of STD Nursing Endocrine Increased Thirst Increased Urination Increase in Hunger Increased Sweating Blood / Lymph Nodes Easy Bruising Gums Bleed Easy Excessive Bleeding Heavy Asprin use Neurological Seizures Weakness / Paralysis Numbness Tremors Immunologic Hives Itching Runny Nose Sinus Pressure Signature*