Patient Information

Patient Legal Name

Today's Date

Patient Preferred Name

Date of Birth

Occupation

Hobbies

Tobacco Use

never used

formerly used

Year Quit

Years of Tobacco Use

Tobacco Types

cigarette

electronic/vaping

cigar

pipe

smokeless (chew)

Average use per day

FAMILY HISTORY

Check if true, family history is

unknown

Place an ✓ in the appropriate box as it applies to your blood relatives

Glaucoma

Father

Mother

Brother

Sister

Son

Daughter

Grandparent

Macular Degeneration

Father

Mother

Brother

Sister

Son

Daughter

Grandparent

Retinal Detachment

Father

Mother

Brother

Sister

Son

Daughter

Grandparent

Strabismus (crossed eye)

Father

Mother

Brother

Sister

Son

Daughter

Grandparent

Personal History

Check any that apply to you

ENDOCRINE

Year diagnosed (diabetes)

If other (Endocrine)

If cancer

If other

Eye Drops (including over the counter)

Other Medications (including over the counter)

Medication Allergies

Past Eye Injuries

Past Eye Surgeries (include dates)

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Health History Form

Patient Information

FAMILY HISTORY

Place an ✓ in the appropriate box as it applies to your blood relatives

Personal History

Check any that apply to you

EYES

ENDOCRINE

CARDIOVASCULAR

NEUROLOGIC

GENITOURINARY

GASTROINTESTINAL

RESPIRATORY

OTHER

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank You!