Patient Health History

Thank you for choosing our practice.
To better serve you, please fill out the information below to the best of your ability.

* - required

Patient's Full Name

First Name

Middle Initial

Last Name

Date of Birth

Account #:

Address

City

State

Zip Code

Home Phone Number:

Cell Phone Number:

Primary Care Doctor

Referring Doctor

Preferred Pharmacy

Preferred Pharmacy Location

Emergency Contact Name

Relationship

Emergency Contact Phone Number

Occupation (if retired, former occupation)

Eye History

Do you currently wear:

Glasses

Contact Lenses

Neither

Are you currently using any prescription or non-prescription medications for your eye(s)?

Yes

If yes, please list:

Have you ever had eye surgery?

Right Eye:

Yes

Type of Surgery:

Date of Surgery (if known):

Type of Surgery:

Date of Surgery (if known):

Left Eye:

Yes

Type of Surgery:

Date of Surgery (if known):

Type of Surgery:

Date of Surgery (if known):

Medical History

Do you have or have you ever had:

1. Heart Disease? (heart attack, coronary artery disease, angina, chest pain, irregular heart rate or palpitations, congenital heart disease, rheumatic heart disease, murmur)

Yes

2. Respiratory Disease? (asthma, emphysema, COPD, chronic cough, bronchitis)

Yes

3. Stroke?

Yes

4. Heart surgery? (bypass or stent)

Yes

5. Pacemaker?

Yes

6. High blood pressure?

Yes

7. Snoring or sleep apnea?

Yes

8. Difficulty with anesthesia?

Yes

9. Bleeding disorder, anemia?

Yes

10. Liver disease?

Yes

11. Kidney disease?

Yes

12. Diabetes? (Type 1 or Type 2)

Yes

13. Thyroid disease?

Yes

14. Cancer?

Yes

Allergies

Are you allergic to any medications?

Yes

If yes, please list:

Are you allergic to latex?

Yes

Please list ALL medications you are currently taking,
including over-the-counter, prescriptions, and vitamins:

Medication	Dosage	Times Per Day

Review of Symptoms

Are you currently experiencing problems with any of the following?

Heart (chest pain, angina, irregular heart beat)?

Yes

If yes, please list:

Respiratory (coughing, wheezing, shortness of breath, asthma)?

Yes

If yes, please list:

Ear/Nose/Throat (sore throat, sinus problems, earache, hearing loss)?

Yes

If yes, please list:

Gastrointestinal (belly pain, heartburn, bowel problems, vomiting)?

Yes

If yes, please list:

Urinary (pain when urinating, blood in urine, incontinence)?

Yes

If yes, please list:

Hematologic/Lymphatic (blood disorder, bruising, cuts heal slowly)?

Yes

If yes, please list:

Endocrine (thyroid problems, chronic fatigue, weight gain/loss)?

Yes

If yes, please list:

Integumentary (rashes, dry skin, eczema)?

Yes

If yes, please list:

Musculoskeletal (joint pain, stiffness, muscle pain or weakness)?

Yes

If yes, please list:

Neurological (numbness, headaches, seizures, paralysis)?

Yes

If yes, please list:

Psychiatric (depression, anxiety, insomnia, confusion)?

Yes

If yes, please list:

Allergic/Immunologic (reaction to food, seasonal allergies)?

Yes

If yes, please list:

Social History

Do you drink alcohol?

Never

Rarely

Moderately

Daily

Do you use tobacco?

Never

Formerly

Currently

Family History

Family Relation	Medical/Eye Disease	If deceased, cause of death

To the best of my knowledge, the questions on this form have been accurately answered. It is my responsibility to inform Dr. Saunders' office of any changes in my medical status.

Signature of patient:

Date:

Patient Health History

Thank you for choosing our practice.
To better serve you, please fill out the information below to the best of your ability.

* - required

Eye History

Medical History

Do you have or have you ever had:

Allergies

Please list ALL medications you are currently taking,
including over-the-counter, prescriptions, and vitamins:

Review of Symptoms

Are you currently experiencing problems with any of the following?

Social History

Family History

To the best of my knowledge, the questions on this form have been accurately answered. It is my responsibility to inform Dr. Saunders' office of any changes in my medical status.

Contact Details

Office Hours

Patient Health History

Thank you for choosing our practice.To better serve you, please fill out the information below to the best of your ability.

* - required

Eye History

Medical History

Do you have or have you ever had:

Allergies

Please list ALL medications you are currently taking,including over-the-counter, prescriptions, and vitamins:

Review of Symptoms

Are you currently experiencing problems with any of the following?

Social History

Family History

To the best of my knowledge, the questions on this form have been accurately answered. It is my responsibility to inform Dr. Saunders' office of any changes in my medical status.

Thank you for choosing our practice.
To better serve you, please fill out the information below to the best of your ability.

Please list ALL medications you are currently taking,
including over-the-counter, prescriptions, and vitamins: