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Health History Form

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

Preferred Method of Contact

If you are completing this form for another person, what is your relationship to that person?

Optical Information

Do you wear glasses?
Do you wear contact lenses?
Are you interested in contact lenses?
Are you interested in refractive surgery?
Do you preform fine or close-up work?
Are you outdoors all or part of the time?
Do you have trouble reading signs when driving at night?
Are you bothered by glare from: Overhead lighting?
A computer screen?
Oncoming headlights at night?
Are your eyes sensitive in bright sunlight?

Ocular History Please mark "Yes" if you have history with the following.

Age-related macular degeneration
Amblyopia (Lazy eye)
Blindness-one eye
Blindness-both eyes
History of refractive surgery
Injury to the eye region
Strabismus (Crossed eyes)
Tear film insufficiency (dry eyes)

Medical Information

Are you currently under the care of a physician?
Are you in good health?
Has there been any change in your general health within the past year?
Do you use controlled substances (drugs)?
Do you use tobacco (smoking, snuff, chew, bidis)?
If so, how interested are you in stopping?
Do you drink alcoholic beverages?
Have you had a serious illness, operation or been hospitalized in the past 5 years?
Do you take any blood thinners?
Do you take aspirin on a regular basis?
Are you taking or have you recently taken any prescription or over the counter medicine(s)?

Women Only Are you:

Taking birth control pills or hormonal replacements?
Have you ever had an orthopedic total joint (hip, knee, elbow, finger) replacement?

Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following.

Local anesthetics
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics
Latex (rubber)
Hay fever / seasonal
Food / Other

Please mark "Yes" if you have (or have had) any of the following diseases or problems.

Heart murmur
Mitral valve prolapse
Artificial heart valves
Rheumatic fever
Cardiovascular disease
Congestive heart failure
Coronary artery disease
Damaged heart valves
Heart attack
Low blood pressure
High blood pressure
Congenital heart defects
Rheumatic heart disease
Abnormal bleeding
Blood transfusion
AIDS or HIV infection
Autoimmune disease
Rheumatoid arthritis
Systematic lupus erythematosus
Sinus trouble
Cancer / Chemotherapy / Radiation treatment
Chest pain upon exertion
Chronic pain
Diabetes type I or type II
Eating disorder
Gastrointestinal disease
GE Reflux / persistent heartburn
Thyroid problems
Hepatitis, jaundice, or liver disease
Fainting spells or seizures
Neurological disorders
Gag Reflex Sensitivity
Sleep disorder
Mental health disorders
Recurrent infections
Kidney problems
Night sweats
Persistent swollen glands in neck
Severe headaches / migraines
Severe / rapid weight loss
Excessive urination
Sensory Processing Disorder
Oral Sensory Sensitivity
Has a physician or previous doctor recommended that you take antibiotics prior to your treatment?
Do you have any disease, condition, or problem not listed above that you think we should know about?

Pharmacy Information


NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.