Seeing is Believing
Nacogdoches: 936-569-8278
Patient Medical History Form
Please fill out all information.

Name
Date
PATIENT MEDICAL HISTORY
Please answer the following questions about your medical status and history.
1. List the medications you are currently taking, if any (include aspirin, vitamins, supplements):
2. Allergies: Do you have any food or drug allergies (including latex, adhesives, shellfish or iodine)?
 Yes     No
If Yes, please list allergies and reaction(s)
3. Have you ever been diagnosed with any Ocular Problems (e.g., Glaucoma, Cataract, Macular Degeneration, other)?
 Yes     No
If Yes, please list:
4. Have you ever had any Ocular Procedures (e.g., Cataract surgery, Glaucoma surgery, Retinal surgeries, Lasik, RK, other)?
 Yes     No
If Yes, please list:
5. Have you ever had any general surgeries/procedures (e.g., Gallbladder, Cardiac, Pacemaker, Appendix, other)?
 Yes     No
If Yes, please list:
REVIEW OF SYSTEMS: Please click to select all conditions that you have.
PLEASE PROVIDE EXPLANATION
 Diabetes
 Cancer
 High Cholesterol
 High Blood Pressure
 Chronic fever, unexpected weight loss/gain, fatigue
 Skin (e.g., rashes, excessive dryness, rosacea, skin cancer)
 Ear/nose/throat (e.g., hearing loss, sinus problems, sore throat, chronic cough)
 Respiratory (e.g., asthma, emphysema, COPD, shortness of breath)
 Cardiovascular (e.g., heart disease, chest pain, irregular heart beat)
 Gastrointestinal (e.g., heart burn, ulcer, abdominal pain, diarrhea, vomiting)
 Urinary (e.g., kidney/bladder conditions, pain or discomfort, blood in urine)
 Musculoskeletal (e.g., arthritis, muscle aches, joint pain, swollen joints)
 Neurologic (e.g., stroke, numbness, awakeness, headaches, paralysis)
 Endocrine (diabetes, thyroid)
 Psychiatric (e.g., depression, anxiety, panic attacks)
 Autoimmune (e.g., lupus, rheumatoid arthritis, HIV/AIDS, hepatitis)
 Environmental Allergies
Race Association: 
 White    Black    Hispanic    Asian    Indian
 Other:
Family History
Have your parents, grandparents or siblings been treated for any of the following? If Yes, please specify who.
Glaucoma
Macular Degeneration
Heart Disease
Diabetes
Retinal Detachment
Cancer
Blindness
Unexplained Vision Loss
Social History
Do you drink alcohol?  Yes   No
Are you pregnant?  Yes   No
Do you smoke?  Yes   No
Former Smoker?  Yes   No
5300 North Street
Nacogdoches, TX 75965
Phone: 936-569-8278
Fax: 936-569-0275
1-800-753-3846
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