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Forms

Make an Appointment Patient Registration Patient Medical History Feedback Survey Dry Eye Questionnaire

Medical History

PATIENT MEDICAL HISTORY

Age 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 State AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Gender Male Female Marital Status Single Married Divorced Widowed Exam Type Wanted Check Up For Glasses For Contact Lenses For Glasses & Contacts LASIK Consultation Medical Consultation Exam Follow Up Contact Follow Up Surgical Follow Up Not Sure

Do you currently wear:

Glasses YES NO Type Distance Reading Computer Progressives Bifocals For What Activities? All the time Distance Reading Computer Sport Safety Sun Contact Lenses YES NO Type Soft Gas-Permeable Keratoconus Days a Week occasionally 1-2days 3-5days 5-7 days Hours per Day 0-4 hours 4-8 hours 8-12 hours 12-16 hours overnight Dispose Contacts daily 1 week 2 weeks monthly quarterly annually

Do you currently have or have you ever had any of the following:

Eye Symptoms YES NO Headaches Double Vision Flashes Floaters Blurred Distance Vision Blurred Near Vision Blurred Night Vision Dry/Sandy Sensation Burning Pain Redness Mucus Tearing/Watering Eye History YES NO Eye Surgery Eye Infection/Disease Eye Injury Amblyopia Dry Eyes Other Detail

Family Eye History - Anyone in patient's family (blood relative) had any of the following?   Glaucoma YES NO Cataracts Retinal Detachment Macular Degeneration Blindness

Do you Have or a family member have?

Yes No How Long? High Blood Pressure Years less than 1 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years more than 25 Diabetes Years less than 1 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years more than 25 Heart Condition Years less than 1 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years more than 25 Thyroid Condition Years less than 1 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years more than 25 Cancer Years less than 1 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years 21 Years 22 Years 23 Years 24 Years 25 Years more than 25

Do you have problems with any of these systems? - Please check all that apply   Allergic / Immunologic YES NO Arthritis Blood / Lymph Cardiovascular Heart Disease Ear / Nose / Throat Endocrine Glands Gastrointestinal Integument Skin Kidney Problems Musculature Nervous Psychiatric Respiratory Skeletal Bones Other (explain bottom of page) Are you pregnant/nursing?

Do you use - Please select all that apply     YES NO   Cigarettes? Packs per Day ½ Pack a Day 1 Pack a Day 1½ Packs a Day 2 Packs a Day 2½ Packs a Day 3 Packs a Day More than 3 Alcohol? Frequency Social Drinker Occasionally 1 Drink a Day 2 Drinks a Day 3 Drinks a Day 4 Drinks a Day 5 Drinks a Day More than 5 1 Drink a Week 2 Drinks a Week 3 Drinks a Week 4 Drinks a Week 5 Drinks a Week More than 5 1 Drink a Month 2 Drinks a Month 3 Drinks a Month 4 Drinks a Month 5 Drinks a Month More than 5 Other substances? Substances Prescribed substances Un-prescribed substances

Allergies - List any known Allergies:   Do you currently have any Allergies YES NO known or perceived?

Medication - List any Medications:   Are you currently taking YES NO prescription or non-prescription drugs?

Your Surgical History- List any type of surgery and dates of surgery

Vision Correction Preferences, Interests- Put a check in any boxes that interests you   EYEGLASSES Extra thin and light eyeglass lenses Anti-Reflective Coating (Glare-Free) lenses. Reduce eyestrain. Great for night vision & computers Designer frames - Lindberg, Lafont, 2.5 Eyephorics, Pro-Design, Prada etc. Lightweight Frames Invisible bifocal (No-Line progressives) - Varilux Transitions Lenses- Lenses that auto-adjust to light level (In/Out door) Tinted Lenses Only Specialty Glasses - Sports Frames, Snorkel/Scuba masks, swim, ski Motorcycle, Etc. Discount for second pair Referral Discount CONTACT LENSES Contacts that are comfortable ALL day long Disposable Contact Lenses Overnight Contact Lenses Daily Disposable Contact Lenses that correct astigmatism Colored Contact Lenses Bifocal Contact Lenses SUNGLASSES Prescription Sunglasses UV (Ultra-Violet) light protection Polarized lenses -considerably reduces sun & reflective glare, & eliminates horizontal reflections Sunglasses to wear with Contact Lenses LASER VISION CORRECTION Laser vision correction CHILDREN'S VISION Age of Children's First Eye Exam IL State Law regarding annual eye exams Contact lens wear for children Protective Glasses

Other Information- Please elaborate on any information or from any "Other" box above.   Notes