Optometrist in Weyauwega, WI
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Patient History Form
Name
First
Last
Date of Birth
Date Format: MM slash DD slash YYYY
Today's Date
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Sex
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Female
Name of Primary Care Physician
Address of Primary Care Physician
Street Address
Address Line 2
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ZIP Code
Please list all prescribed and over the counter medications you are currently taking:
Please list name and for what condition/dosage.
Drug Allergies
Yes
No
Please list
Environmental Allergies
Yes
No
Please list
Are you experiencing any of the following visual problems while wearing your glasses or contacts?
Check all that apply
Difficulty reading small print
Difficulty driving
Bothered by glare/halos
Eyestrain with computer work
Have you ever been diagnosed with, or treated for any of the following:
Lungs
Check all that apply
Asthma
Emphysema
Other
Please List
Endocrine
Check all that apply
Diabeties - Adult Onset
Diabeties - Childhood Onset
Thyroid Problems
Other
Please List
Last Blood Sugar & Date
Heart
Check all that apply
Congestive heart failure
Heart attack(s)
Elevated cholesterol
Other
Please List
Nervous System
Check all that apply
Hearing problems
Fainting or dizziness
Migraine headaches
Convulsions/Epilepsy/Seizures
Stroke/Paralysis/TIA
Other
Please List
Gastrointestinal
Check all that apply
Irritable bowel syndrome
Other
Please List
Musculo-Skeletal
Check all that apply
Arthritis
Lupus
Other
Please List
Psychiatric
Check all that apply
Depression
Schizophrenia
Anxiety
Other
Please List
Blood pressure
Check all that apply
High blood pressure
Low blood pressure
Anxiety
Other
Please List
Genitourinary
Check all that apply
Kidney disease
Pregnant
Other
Blood
Check all that apply
Anemia
Blood or bleeding disorders
Other
Cancer
List type(s) if applicable
Eye History
Do you have, or have you ever had any of the following:
Check all that apply
Cataracts
Glaucoma
Macular Degeneration
Retinal Problems
Diabetic Retinopathy
Eye muscle problems
Optic nerve problems
Other
Please list
Do you use eye drops?
Yes
No
If yes, please list the names and dosage of drops
Previous Eye Surgeries
Please fill out information for any that apply.
Cataract Surgery
Please list date and surgeon
Yag Capsulotomy
Please list date and surgeon
Retinal Detachment Repair
Please list date and surgeon
Focal Macular Laser
Please list date and surgeon
Glaucoma Argon Trabeculoplasty
Please list date and surgeon
Trabeculectomy
Please list date and surgeon
Glaucoma Drainage Implant
Please list date and surgeon
Other Eye Surgery
Please list date and surgeon
Family Eye History
Cataracts
Yes
No
Relationship to Patient
(Sibling, Parent, or Grandparent)
Glaucoma
Yes
No
Relationship to Patient
(Sibling, Parent, or Grandparent)
Macular Degeneration
Yes
No
Relationship to Patient
(Sibling, Parent, or Grandparent)
Diabetic Retinopathy
Yes
No
Relationship to Patient
(Sibling, Parent, or Grandparent)
Eye Muscle Problems
Yes
No
Relationship to Patient
(Sibling, Parent, or Grandparent)
Retinal Detachment
Yes
No
Relationship to Patient
(Sibling, Parent, or Grandparent)
Blindness
Yes
No
Relationship to Patient
(Sibling, Parent, or Grandparent)
Other Ocular Problems
Yes
No
Explanation
Contact Lenses
Have you ever worn contact lenses?
Yes
No
Doctor's office that provided last prescription
Are you interested in contact lenses?
Yes
No
Which pharmacy do you use for prescriptions?
Address of pharmacy
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
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Virgin Islands, U.S.
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Patient or Guardian's Signature
First
Last
Date
Date Format: MM slash DD slash YYYY
Office Hours
Mon
day
8:00am
5:00pm
Tues
day
8:00am
5:00pm
Wed
nesday
8:00am
5:00pm
Thurs
day
8:00am
5:00pm
Fri
day
8:00am
12:00pm
Sat
urday
Closed
Sun
day
Closed
Beginning Monday, May 11th, we will be returning to normal business hours and will be seeing patients for all types of vision exams. We are following all COVID-19 guidelines, including sanitizing, wearing face masks and practicing social distancing.
