Patient History Form

Family History

Please note any family history (parents, grandparents, siblings, children):

Blindness

Relation to You How?

Cataract

Relation to You

Crossed Eyes

Relation to You

Glaucoma

Relation to You

Macular Degeneration

Relation to You

Retinal Detachment

Relation to You

Rheumatoid Arthritis

Relation to You

Cancer

Relation to You

Diabetes

Relation to You

Heart Disease

Relation to You

High Blood Pressure

Relation to You

Kidney Disease

Relation to You

Lupus

Relation to You

Thyroid Disease

Relation to You

Social History

This information is kept strictly confidential. However, you may discuss this portion directly with your doctor if you prefer.

Please check the box if you wish to discuss your Social History directly with your doctor

Do you drive?*

Yes
No

If yes, describe any visual difficulty while driving:

Do you smoke?*

Yes
No
Former Smoker

If you’re a current smoker, for how long? How many years?*

If you’re a former smoker, for how many years were you a smoker?*

When did you quit?*

Do you use tobacco products?*

Yes
No

If yes:*

Type Amount (packs) How long (years)

Do you drink alcohol?*

Yes
No

If yes:*

Type Amount per day How long Only Social

Do you use illegal drugs?*

Yes
No

If yes:*

Type Amount How long

Indicate by checking the box if you have been infected with or exposed to:

Gonorrhea
Hepatitis
HIV
Syphilis
MRSA

Signature:*

Date:*

Patient History Form

For a printable form click here

Step 1 of 5

Demographics

Ocular / Medical History

Review of Systems

Family History

Social History

Liverpool

Fayetteville