Health History Form

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Home Previous Page	Health History Form The information requested on this form will help us expedite your examination. If you have any questions about completing this form, please call us at 770-499-2020 or email us. When you finish filling out this form, use the submit button to send via secure internet connection.

		Health History
	First Name
	Last Name
	Age
	Email Address
	Reason for Visit
	Age of Present Glasses
	Date of Last Eye Exam
	From Doctor


		Family History
		Do You or any Blood Relatives have:
	Diabetes:	Yes No
	Who?
	If Other, please indicate:
	High Blood Pressure:	Yes No
	Who?
	If Other, please indicate:
	Heart Disease:	Yes No
	Who?
	If Other, please indicate:
	Cataracts:	Yes No
	Who?
	If Other, please indicate:
	Glaucoma:	Yes No
	Who?
	If Other, please indicate:
	Retinal Detachment:	Yes No
	Who?
	If Other, please indicate:
	Retinal Degeneration:	Yes No
	Who?
	If Other, please indicate:
		General Health
	Are you taking any Medications?	Yes No
	Please List:

	Are you allergic to any Medications?	Yes No
	Please List:

	Have you ever had your eyes dilated?	Yes No
	Describe Reactions:

	Do you ever see double?	Yes No
	When?

	Do you have frequent headaches?	Yes No
	When?

	Have you ever had an eye infection, disease, injury or surgery?	Yes No
	Please list:

	Do you have trouble with night vision?	Yes No

	Are you light sensitive?	Yes No

		Social History

	Do you use alcohol?	Yes No
	Do you use tobacco?	Yes No
	Other (e.g. herbs, caffiene)?	Yes No
	Do you work with a computer?	Yes No
	What hobbies / sports do you enjoy?

		Contact Lens History
	Are you interested in new contacts?	Yes No
	Have you ever worn contact lenses?	Yes No
	Do you now wear contact lenses?	Yes No
	How old are your contact lenses?
	Type of Contacts Worn (click all that apply):	Disposable Gas Permeable Soft Extended Wear Toric-Astigmatism Bifocal Hard
	Have you ever had a reaction to eye drops or contact lens cleaning solutions?	Yes No
	Please describe:

	Do you have interest in corrective eye procedures?	Yes No

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the eye doctor to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the paired of such eye care to third party payers and/or health practitioners. Yes No I authorize and request my insurance company to pay directly to the eye doctor insurance benefits otherwise payable to me. I agree to be responsible for payment of all services rendered on my behalf or my dependents that exceeds the amount that my insurance allows. Yes No

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