Optical Health Forms

Optical Health Forms
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Visual and Health Information

Hello and welcome to our practice! We are excited to work with you today. Please take a few minutes to fill out this questionaire to the best of your ability. This is information we need to know in order to determine a proper diagnosis.

Please Circle if you are here for:
Do you wear glasses?
Do you wear contacts?
Have you had corrective eye surgery in the past?
May we dilate the patient?

Birth Information

Birth Defects?
On Oxygen?
Place a check by your symptoms.

Has the patient ever had:

Select yes or no to each of the questions below.

Recently, have you had trouble with weight gain or weight loss?
Are you feeling tired or sick today?
Are your eyes, ears, nose or throat giving you trouble today?
Are you currently feeling any anxiety, depression or symptoms of ADHD?
Recently, have you experienced racing or irregular heart beats, heart murmurs, dizzy spells or chest pains?
Do you have trouble urinating or urinate frequently?
Currently, are you experiencing skin problems such as acne, skin rashes, sores, eczema, psoriasis, etc.?
Do you have problems with joints (knee, hip, etc.), body aches or arthritis?
Are you experiencing wheezing, shortness of breath or respiratory issues?
Currently, are you feeling numbness or tingling sensations, dizziness, or inability ot move one side of your body?
Are you experiencing nausea, heartburn, diarrhea, constipation, bloating or stomach pains?
Do you smoke?
Please choose all that apply:

Do you drink?
Please choose all that apply.

Family Medical HistoryPlace a check by all that apply to the Family's past medical history:

Ocular - Strictly eye medical history

Medical - Strictly personal health history

Allergies and Medicatons

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