Fillable Henry Eye Clinic Medical History Form Fillable 2019

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Henry Eye Clinic Medical History Form Fillable 2019

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The Henry Eye Clinic Medical History Form Fillable 2019 form is 1 page long and contains:

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  • 73 check-boxes
  • 67 other fields

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File type: PDF

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Henry Eye Clinic Date __________________
MEDICAL HISTORY QUESTIONNAIRE
Name _______________________________________________ Birth Date __________________________
Referred by: ________________________________ Family Doctor: ______________________________________
Current Medications List Supplied
________________________________________________________________________________________________
________________________________________________________________________________________________
Food or Drug Allergies List Supplied
________________________________________________________________________________________________
__
______________________________________________________________________________________________
Do you now have or have you recently had any of the following:
Light Sensitivity
Trouble Focusing
Dryness
Wear Contacts
Redness
Pain
Discharge
Previous Corneal Surgery
Flashing Lights
Double Vision
Glare
Flomax Use
Floaters
Distorted Vision
Tobacco Use
Itchiness
Decreased Vision
Alcohol Use
HEALTH CONDITIONS NONE SURGICAL NONE Year
Explain / Comments
_________
_______________
Cardiac CABG / Pacemaker / Stent
_________
_______________
Cholecystectomy
_________
_______________
Gastric bypass
_________
_______________
Hip replacement
RT LT
_________
_______________
Knee replacement
RT LT
_________
_______________
Back surgery
_________
_______________
Other _______________________________________________
_______________
_______________
_______________
_______________
FAMILY HISTORY: NONE ADOPTED
Type I x_______yrs
Type II x_______yrs
S/B= Sister or Brother, M= Mother, F= Father
_______________
_______________
List How Related
_______________
_______________
Amblyopia
_________
Migraines
_________
_______________
Arthritis
_________
Seizure disorder
_________
_______________
Asthma
_________
Stroke
_________
_______________
Blindness
_________
Thyroid disorder
_________
_______________
Cancer
_________
Other: _________________________
_______________
Cardiovascular disease
_________
_________________________
_______________
Diabetes
_________
_________________________
_______________
Glaucoma
_________
_________________________
_______________
High Cholesterol
_________
_________________________
_______________
Hypertension
_________
_________________________
_______________
Macular degeneration
_________
_________________________
I affirm the information I provided regarding my medical and patient information to be complete and accurate.
I understand and agree regardless of insurance status, I am responsible for the balance on this account for any professional services
rendered.
I acknowledge that I have been provided access to Henry Eye Clinic’s Notice of Privacy Policies.
Patient Signature________________________________________________________________________
Physician’s Signature ____________________________________________________________________ Date _____________________
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Henry Eye Clinic Medical History Form Fillable 2019

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Completed 24 January 2022

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