InVision EyeCare Medical History
Patient Name:______Age:______Sex: Male / FemaleDate:______
Allergies:______
History of the following diseases: (Please indicate with a check if present)
Self / FamilySelf / Family
General/ConstitutionalRespiratory
Cancer____ / ____Asthma____ / ____
Significant weight loss/gain____ / ____COPD____ / ____
Emphysema____ / ____
Skin/IntegumentarySleep Apnea____ / ____
Rash____ / ____Other______/ ____
Melanoma____ / ____
Eczema____ / ____Cardiovascular/Vascular
Psoriasis____ / ____Diabetes____ / ____
Rosacea____ / ____High blood pressure____ / ____
Shingles____ / ____High cholesterol____ / ____
Other______/ ____Stroke____ / ____
TIA____ / ____
NeurologicalHeart disease____ / ____
Chronic headache____ / ____Irregular heart beat____ / ____
Migraines____ / ____Chest pain____ / ____
Epilepsy/seizures____ / ____Dizziness____ / ____
Multiple Sclerosis____ / ____
Tingling/numbness____ / ____Immunologic
Lupus____ / ____
EndocrineTuberculosis____ / ____
High thyroid____ / ____HIV/AIDS____ / ____
Low thyroid____ / ____Hepatitis____ / ____
Hormonal imbalance____ / ____Liver disease____ / ____
Sarcoidosis____ / ____
Lymphatic/Blood Disorders
Anemia____ / ____Genitourinary
Bleeding tendency (hemophilia)____ / ____Kidney disease____ / ____
Increased blood clotting____ / ____Prostate disease____ / ____
Sickle Cell ____ / ____Ovarian disease____ / ____
Leukemia____ / ____Sexually transmitted disease____ / ____
Ears/Nose/Mouth/ThroatBones/Joints/Muscles
Hearing Loss____ / ____Rheumatoid Arthritis____ / ____
Chronic allergies____ / ____Chronic joint/muscle pain____ / ____
Sinus congestion____ / ____Fibromyalgia____ / ____
Chronic cough____ / ____Osteoporosis____ / ____
Recurrent cold sores____ / ____
Psychiatric
GastrointestinalDepression____ / ____
Ulcers____ / ____Anxiety____ / ____
Colitis____ / ____Attention deficit disorder____ / ____
Irritable bowel syndrome____ / ____Bipolar disorder____ / ____
Crohn’s Disease____ / ____Schizophrenia____ / ____
Previous surgeries:______
Tobacco use: Yes / NoAlcohol use:Yes / No Drug/Substance abuse: Yes / No
~Continued on back~
Current Medications:______
______
______
If you are female, possibility of pregnancy? Yes / No
Ocular History
History of eye diseases:(Please indicate with a check if present)
Self / Family
Glaucoma____ / ____
Cataracts____ / ____
Macular Degeneration____ / ____
Retinal Detachment____ / ____
Blindness____ / ____
Retinal Disease____ / ____
Color Blindness____ / ____
Strabismus (eye turn)____ / ____
Amblyopia (“Lazy” eye)____ / ____
Other______/ ____
Do you suffer from any of the following:
Blurry Vision______Sinus Problems______Flashes of Light______
Dry Eyes______Headaches______Halos______
Watery Eyes______Pain in your eyes______Floaters______
Seasonal allergy______Dizziness______Other______
Have you ever had any serious trauma to your eyes? Yes / No ______
Have you ever had any serious eye infections? Yes / No ______
Do you use any prescription or non-prescription eye drops? Yes / No ______
Contact Lens History
Contact Lens use? Yes / NoWhat kind?Soft / HardBrand:______
Current replacement schedule? ______Brand of cleaning solution: ______
Do you ever sleep in your contact lenses?Yes / No (If Yes, how often?______)
Approximate date of last eye exam:______Present eye doctor:______
Approximate date of last physical exam:______Present medical doctor:______
Purpose of today’s visit:______