Medical History

First Name

Last Name

Date of Birth

Date

Height

Weight

Race

Ethnicity

Preferred Language

Do you have allergies to any medication? If yes, list them and describe reaction:

Medical History

List major injuries, surgeries, and/or hospitalizations you have had:

Are you pregnant or nursing?

YesNo

Eye Diseases

Other

YesNo

Additional Notes

Current Eye Symptoms

Review of Systems

Select if you have problems with any of these systems:

Family History

Have any blood relatives (parents, grandparents, siblings, children) had any of the following:

Blindness

Crossed or Lazy Eyes

Glaucoma

Macular Degeneration

Retinal Detachment

Significant Arthritis

Diabetes

Heart Disease

High Blood Pressure

Other Serious Eye Disease

Please list any other family history of serious eye conditions not listed above.

Social History

Occupation

Do you drink alcohol?

Do you use illegal drugs?

YesNo

Do you engage in regular exercise?

YesNo

Marital Status

How many hours a day do you use the computer?

Distance from computer?

Do you Drive?

Do you currently wear glasses?

YesNo

Glasses owned

Single VisionSafety GlassesBifocalsSports GlassesTrifocalsProgressiveBack-up GlassesOther

Special Eyewear Needs

Computer (special prescriptions, special anti-glare tints or coatings)Safety Glasses (gardening, woodworking, welding)Occupational (mechanics, plumbers, pilots)Sports/Hobbies (racquet sports, motorcycle)

Hobbies/Interests

If not contact lens wearer, are you interested in trying contact lenses at this time?

YesNo

Do you currently wear contact lenses?

YesNo

Type and brand of contact lenses?

How many hours/day?

How many days/week?

How Often Do You Replace Your Contact Lenses?

What contact lens solution do you use?

For School Children Under Age 19:

Were there any complications in the prenatal, birth, or postnatal time period?

YesNo

Is the child's physical and mental development normal?

YesNo

Is the child's school performance satisfactory?

YesNo

List any persons you wish to allow the doctor to talk to about your medical information:

Check the box to agree to the privacy policy.

Patient Name as Signature

Medical History Form

All Eye Care Services

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American Fork

Lehi

Medical History

Medical History Form

All Eye Care Services

Keep In Touch

American Fork

Lehi

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