South Grove Eye Care

Patient Medical History

Name _________________________________________________Date of Birth______/______/______

Medical Doctor ____________________________________Last Medical Exam___________________

Medications (please list over-the counter also) ______________________________________________________________________________________ ______________________________________________________________________________________

Do you have allergies to medications? Yes No

If “yes” please list ______________________________________________________________________

Do you wear glasses? Yes No

Do you wear contact lenses? Yes No

If “yes” to contact lenses, what type of lenses do you wear? _____________________________________

Do you sleep in your lenses? Yes No

Review of Systems

Do you currently have any of the following conditions?

If “yes” please explain

Heart (irregular heartbeat, chest pain) Yes No________________________________

Respiratory (asthma, shortness of breath) Yes No________________________________

Gastrointestinal (abdominal pain, heartburn) Yes No________________________________

Urinary (pain with urination, blood in urine) Yes No________________________________

Skin (eczema, rosacea) Yes No________________________________

Musculoskeletal (arthritis, muscle aches) Yes No________________________________

Neurological (headaches, paralysis, numbness) Yes No________________________________

Psychiatric (depression, anxiety) Yes No________________________________

Ear/Nose/Throat (sinus problems, hearing loss) Yes No________________________________

Endocrine (diabetes, thyroid) Yes No________________________________

Are you pregnant or nursing? Yes No

Family History

Have you or any member of your family (parent, grandparent or sibling) had any of the following conditions?

Cataract Self Family Diabetes Self Family

Glaucoma Self Family Asthma Self Family

Macular Degeneration Self Family Migraines Self Family

Lazy Eye Self Family Seizures/Epilepsy Self Family

Retinal Detachment Self Family Arthritis Self Family

Blindness Self Family Thyroid Disease Self Family

High Blood Pressure Self Family Cancer Self Family

Heart Disease Self Family Liver Disease Self Family

Stroke Self Family Anemia Self Family

Other conditions – please list _____________________________________________________________________________________________________________________________________________

Surgeries – Please list surgeries, including eye surgeries

_____________________________________________________________________________________________________________________________________________

Social History

Do you smoke? Yes No If yes, how much? ___________________________

Do you drink alcohol? Yes No If yes, how much? ___________________________

Are you using or have you used recreational drugs? Yes No

Patient or Guardian Signature ______________________________Date __________