Plaza Lane Optometry

Medical History Form

General Information

Legal Name:  

Birth Date: 

Last Medical Exam: 

Last Eye Exam: 

Personal Medical History

Do you have any allergies to medications? Yes No

If yes, explain:

List any medications you take (including oral contraceptives, aspirin, over-the-counter medications and home remedies):

List all major injuries, surgeries and/or hospitalizations you have had:

Check any of the following that you have had:

 Crossed Eyes Lazy Eye Drooping Eyelid Prominent Eye Glaucoma/Retinal Disease Cataracts Eye Infections Eye Injury

If you selected any of the conditions above, please explain in further detail:

Do you experience symptoms of nausea while reading in a moving car?
 Yes No

Are you pregnant and/or nursing? Yes No

Do you wear glasses? Yes No

If yes, how old are they? 

Do you currently wear contact lenses? Yes No

If Yes, What Type? Rigid Soft Wear Over-Night

If you do not wear contact lenses now but have worn them in the past, when did you last wear your lenses? 

Family History

Please check any family history (parents, grandparents, siblings and/or children, living or deceased) for the following medical conditions:

 Blindness Cataract Crossed Eyes Glaucoma Macular Degeneration Retinal Detachment/Disease Arthritis Cancer Diabetes Heart Disease High Blood Pressure Kidney Disease Lupus Thyroid Disease

Please provide the condition(s) and relationship to you:

Social History

Do you drive? Yes No

If yes, do you have visual difficulty when driving? Yes No

If yes, please describe:

Review of Systems

Do you currently have any problems in the following areas: (If YES, please explain and list medications)

Neurologic

 Headaches Migraines Seizures

Eyes

 Loss of Vision Blurred Vision Distorted Vision/Halos Loss of Side Vision Double Vision Dryness Mucous Discharge Redness Sandy or Gritty Feeling Itching Burning Foreign Body Sensation Excess Tearing/Watering Glare/Light Sensitivity Eye Pain or Soreness Chronic Infection of Eye or Lid Sties or Chalazion Flashes Floaters Tired Eyes

Ears, Nose, Mouth, Throat

 Allergies Hay Fever Sinus Congestion Post-Nasal Drip Chronic Cough

Respiratory

 Asthma Chronic Bronchitis Emphysema

Bones/Joints/Muscles

 Rheumatoid Arthritis Muscle Pain Joint Pain

Describe:

Digital Signature

By typing my name in the text box below, I am validating that all of the above information is accurate and up-to-date.

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