Patient History Form Step 1 of 4 25% Patient History FormPlease complete the information below and submit the form online. This form contains confidential information and is delivered to your doctor through a secure Internet connection.Please help us take better care of your overall health by completing the following formName* First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Number*Please provide a telephone number, with area code, so we can contact you. Cell PhoneWork PhoneWill you be using your FSA Card or HSA Card? Yes No You can use your FSA/HSA benefits towards any purchase at our practice.Email AddressPlease provide your email address. Employer Occupation* Date of Birth* MM slash DD slash YYYY Social Security Number (last 4 digits only!)Please enter a number from 0000 to 9999.Race/Ethnicity Preferred Language Gender Female Male Who may we thank for referring you to our office?* Date of Last Medical Exam Name of Medical Doctor Doctor's Phone Number Date of Last Eye Exam* Name of Previous Eye Physician Spouse or Guardian (If Applicable) PLEASE CHECK ALL THAT APPLYOCULAR HISTORY Cataract Glaucoma Retinal Detachment Macular degeneration Corneal Abrasion(s) Keratoconus Eye Turn/Lazy Eye(s) Flashes of light/Floaters Tired Eyes Double Vision Glare/Light Sensitivity Other Other: Please Specify OCULAR SURGERY Cataract Glaucoma Retinal Surgery LASIK Cross-Linking Corneal Transplant Other Other: Please Specify HiddenIf Other Eye Disorders or Surgeries, please explain: Do you wear glasses? No Yes If Yes, how old is your current pair of glasses? Please bring your most recent pair of glasses to your eye exam.Do you wear sunglasses? No Yes Do you wear contact lenses? No Yes If Yes, how old is your current pair of contact lenses? Do you sleep in your contact lenses? No Yes Type of Contact Lenses: Rigid Soft Extended Wear Other If Other, please explain: Are your contact lenses comfortable? No Yes What type(s) of activities do you engage in outdoors? Check all that apply. Driving Running Tennis Walking Hiking Biking Golfing Gardening Other If Other, please explain: On average, how many hours per day do you spend looking at a screen (computer, phone, tablets, etc)?* None 1-4 hours 5-8 hours 8-12 hours more than 12 hours MEDICAL HISTORYList any medications you take, including oral contraceptives, aspirin, over-the-counter medicines, etc.:*Include Name of Medication, Dosage, Frequency TakenDo you have any allergies to medications?* No Yes If Yes, list medication(s) and reaction(s) below:List all major injuries, surgeries and/or hospitalizations you have had:Are you pregnant or nursing? No Yes Have you ever been exposed to or infected with: Gonorrhea Hepatitis HIV Syphillis REVIEW OF SYSTEMSCARDIOVASCULAR Elevated Cholesterol Heart Disease Hypertension ENDOCRINE Crohn’s Disease Diabetes Mellitus Pituitary Disorder Renal (kidney) Disorder Thyroid Disorder GASTROINTESTINAL Acid Reflux Cancer, Colon, Liver, Lung Hepatitis Gastritis GENITOURINARY Ovarian Disorder Prostate Disorder EAR, NOSE, MOUTH, THROAT Dry Mouth Ear Infection Sinusitis IMMUNOLOGIC Acquired Immune Deficiency Herpes Simplex Herpes Zoster HIV Positive Lyme Disease Rubella Sarcoid Sjogren’s Syndrome NEUROLOGICAL Bell’s Palsy Headache Nystagmus Parkinson’s Disease Seizure Disorder RESPIRATORY Asthma Sleep Apnea Lung Disease Tuberculosis HEMATOLOGIC/LYMPHATIC Anemia Blood Disorder Sickle Cell Disease INTEGUMENTARY (SKIN) Acne Acne Rosacea Dermatitis Lupus MUSCULOSKELETAL Arthritis Muscular Dystrophy Myasthenia Gravis Rheumatoid Arthritis PSYCHIATRIC Anxiety Disorder Dementia Depression Mood Disorder Family HistoryNote any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions.Disease/Condition Blindness Cataract Crossed Eyes Glaucoma Macular Degeneration Retinal Detachment or Disease Cancer Diabetes Heart Disease High Blood Pressure Thyroid Disease Other If Other, please explain: If yes, please list which family member(s)?Social HistoryThis information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer. Please check the box below of you prefer to discuss with the doctor instead.I prefer to discuss my Social History information directly with my doctor. Yes Do you use tobacco products? No Yes If Yes, list type/amount/how long:Do you drink alcohol? No Yes If Yes, list type/amount/how long:Patient Signature*Date* MM slash DD slash YYYY Optomap (Optos) Retinal Imaging The doctor strongly recommends the Optomap. The optomap can provide an ultra-widefield 200-degree retinal view. While eye exams generally include a look at the front of the eye to evaluate health and prescription changes, a thorough screening of the retina is critical to verify that your eye is healthy.​ It can lead to early detection of common diseases, such as: Macular degeneration Glaucoma Bleeding in the retina Cancer This test is quick, painless, and does NOT require dilation drops. iWellness OCT Retinal Scan The iWellness Exam is state-of-the-art technology that lets the doctor see beneath the surface of your retina, where signs of disease first appear. Traditional eye exams and retinal photography do not provide this level of detail. This instrument evaluates the optic nerve for diseases such as glaucoma. It also evaluates for macular degeneration and diabetic retinopathy. This scan is quick and doesn’t use a bright flash. Please check here if you would like the Optos screening alone for $39. Please check here if you would like the Optos screening AND iWellness for $59. Print Patient Name First Last Date MM slash DD slash YYYY Patient Signature Lifestyle IndexThis questionnaire is meant to help your doctor understand what you're experiencing on a regular basis - whether it's caused by your eyes, posture, stress, etc. Your responses will help make sure you receive the best care possible. How often do you experience any of these symptoms?Headaches - of any severity each week, usually getting worse later in the day* 1. Never 2. Rarely 3. Sometimes 4. Very Often 5. Always Stiffness/pain neck/shoulders - when you work at a computer or read* 1. Never 2. Rarely 3. Sometimes 4. Very Often 5. Always Discomfort with Computer Use - in your eyes (redness, burning) after long hours looking at the screen* 1. Never 2. Rarely 3. Sometimes 4. Very Often 5. Always Tired Eyes - with increasing feeling of eye fatigue more gritty/sandy while working at computer or reading* 1. Never 2. Rarely 3. Sometimes 4. Very Often 5. Always Dry Eye Sensation - feeling progressively more gritty/sandy while working at a computer or reading* 1. Never 2. Rarely 3. Sometimes 4. Very Often 5. Always Light Sensitivity - especially with brighter, stronger lights like fluorescents or headlights* 1. Never 2. Rarely 3. Sometimes 4. Very Often 5. Always Dizziness - or an experience like motion sickness or vertigo* 1. Never 2. Rarely 3. Sometimes 4. Very Often 5. Always Your score isCommentsThis field is for validation purposes and should be left unchanged.
