Patient History Form

Patient Name
First Last
Date of Birth
MM slash DD slash YYYY
Gender
- Male
- Female
SSN
Marital Status
- Married
- Single
- Divorced
- Widowed
Sports/hobbies
Spouse/guardian
Race
- American Indian/Alaska Native
- Black/African American
- Native Hawaiian/Pacific Islander
- White
- Other race
- Decline to answer
Ethnicity
- Not Hispanic or Latino
- Hispanic or Latino
- Unknown
- Decline
Height
Weight
Preferred Language
- English
- Spanish
- Other
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Cell Phone
Mother/Guardian’s Name: (if minor)
First Last
SSN
Address if different
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
MM slash DD slash YYYY
Father/Guardian’s Name: (if minor)
First Last
SSN
Address if different
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
MM slash DD slash YYYY
Employer/School:
Occupation/School Grade
Email Address
Preferred Contact
- Cell
- Home
- Text
- Email
- US mail
Emergency Contact
First Last
Relation
Phone Number
Would you like to receive text or email notifications?
- Yes
- No
Primary Care Physician
Date of last medical exam
MM slash DD slash YYYY
Primary physician address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Pharmacy
Pharmacy address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Clinic/Eye Doctor’s Name
First Last
Date of last eye exam
MM slash DD slash YYYY
Do you wear glasses?
- Yes
- No
- All the time
- Sometimes
- Work only
- Reading only
- Driving only
How old are your present glasses?
Do you wear prescription sun glasses?
- Yes
- No
Do you wear contacts?
- Yes
- No
Type
All day comfort?
- Yes
- No
Are you interested in contacts?
- Yes
- No
Are you interested in LASIK?
- Yes
- No
What are your visual symptoms today:
Blurred Vision/Distance
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Blurred Vision/Near
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Double Vision
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Eye Strain
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Eye Infections
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Eye Pain/Soreness
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Tired Eyes
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Burning Eyes
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Itchy Eyes
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Dry Eyes
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Red Eyes
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Watery Eyes
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Wandering Eye
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Mucus Discharge
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Floaters or Spots
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
See Flashes
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
See Halos
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Poor Night Vision
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Headaches
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Migraine Headaches
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Loss of Vision
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Crossed Eyes
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Light Sensitive
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Gritty Feeling
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Poor Color Vision
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Droopy Lid
Which eye?
- Left eye
- Right eye
- Both
Severity
- Low
- Moderate
- High
Pain 0 - 10
Which eye?
- Left eye
- Right eye
- Both
PERSONAL MEDICAL HISTORY (REVIEW OF SYSTEMS)
PLEASE CHECK ANY OF THE FOLLOWING THAT APPLIES TO YOU. IF YOU HAVE NONE OF THESE CONDITIONS, PLEASE CHECK NONE.
Cardiovascular:
- None
- Hypertension (High Blood Pressure)
- High Cholesterol
- Stroke
- Heart Disease
- Other
If other, specify:
Constitutional:
- None
- Cancer
- Trauma/Large Volume Blood Loss
- Developmental Disability
- Other
Type of Cancer
If other, specify:
Neurological:
- None
- Multiple Sclerosis
- Epilepsy
- Cerebral Palsy
- Other
If other, specify:
Dermatologic:
- None
- Eczema
- Rosacea
- Psoriasis
- Other
If other, specify:
Endocrine:
- None
- Thyroid Problem
- Hormonal Dysfunction
- Non-Insulin Dependent Diabetes
- Insulin Dependent Diabetes
- Other
If other, specify:
Ocular:
- None
- Glaucoma
- Macular Degeneration
- Detached Retina
- Diabetic Retinopathy
- Other
If other, specify:
Musculoskeletal:
- None
- Osteoarthritis
- Fibromyalgia
- Muscular Dystrophy
- Ankylosing Spondylitis
- Other
If other, specify:
Reproductive:
- None
- Pregnant
- Nursing
Please list conditions:
Respiratory:
- None
- Asthma
- Bronchitis
- Emphysema
- COPD
- Other
If other, specify:
Psychiatric:
- None
- ADHD
- Depression
- Schizophrenia
- Other
If other, specify:
Immunologic:
- None
- AIDS or HIV
- Rheumatoid Arthritis
- Lupus
- Neurofibromatosis
- Crohns
- Other
If other, specify:
Alcohol Use
- Yes
- No
Amount
Tobacco Use
- Current
- Former
- Never
Amount
Past Medical History
Have you had any operations?
- Yes
- No
What?
Have you ever had an eye injury?
- Yes
- No
Which eye?
- Left
- Right
- Both
What?
Have you ever had eye surgeries?
- Yes
- No
Why?
Have you used eye medications?
- Yes
- No
Why?
Do you get headaches?
- Yes
- No
How often?
Have you ever been diagnosed with?
Cataracts
- Yes
- No
When were you diagnosed?
Glaucoma
- Yes
- No
When were you diagnosed?
Macular Degeneration
- Yes
- No
When were you diagnosed?
Diabetic Retinopathy
- Yes
- No
When were you diagnosed?
I AUTHORIZE OAKLAND VISION to obtain my prescription medications through my pharmacy.
- Yes
- No
Signature
List any medications and their purpose
List any allergies and the reactions
Family History
Has anyone in your family (grandparents, parents, siblings, children, living or deceased) been diagnosed with:
Lupus
- Yes
- No
Relation
High Blood Pressure
- Yes
- No
Relation
Diabetes
- Yes
- No
Relation
Heart Disease
- Yes
- No
Relation
Thyroid Disease
- Yes
- No
Relation
Blindness
- Yes
- No
Relation
Cataracts
- Yes
- No
Relation
Glaucoma
- Yes
- No
Relation
Macular Degeneration
- Yes
- No
Relation
Retinal Detachment
- Yes
- No
Relation

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Patient History Form

What are your visual symptoms today:

PERSONAL MEDICAL HISTORY (REVIEW OF SYSTEMS)

Past Medical History

Family History

Our Locations

Walled Lake

South Lyon

South Lyon

Walled Lake

Be Our Friend Keep up to Date

What are your visual symptoms today:

PERSONAL MEDICAL HISTORY (REVIEW OF SYSTEMS)

Past Medical History

Family History

Our Locations

Walled Lake

South Lyon

Be Our Friend
Keep up to Date