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Home » Patients » Patient forms » Patient Social and Family History

Patient Social and Family History

Patient Name	Date of Birth
Pharmacy Name	Pharmacy Phone Number

Please check all that apply Gender

Male

Female

Preferred Language

English

Spanish

French

German

Other

Race

White

African American

Asian

Black African

American

Mexican American Indian

Other

Ethnicity

Not Hispanic or Latino

Mexican

Latin America

Smoking History

Never

Quit

Currently Smoke

Family History
Check all that apply and explain if related to self or relative

Macular Degeneration
Retinal Detachment
Glaucoma
Diabetes

Ocular History

Have you had Lasik?
Do you wear Contact Lenses?
Have you worn contacts in the past?
Do you have macular degeneration?
Have you had cataract surgery?
Please list any other eye surgeries or eye disease that you have or have had:

REVIEW OF SYSTEMS
Please check each item yes or no as they relate to your health

Eyes

Pain
Double Vision
Floaters
Dry Eyes
Decreased Vision
Excessive Tears
Sandy Feeling

Musculoskeletal

Joint Pain
Stiffness
Arthritis

Ear, Nose, Throat

Hard of Hearing
Ringing in Ears
Vertigo

Gastrointestinal Problems

Stomach
Liver

Blood/Lymph

Easy Bruising
Blood Thinners
Anemia

Kidney/Urinary Problems

Prostate
Bladder
Kidney

Cardiovascular

Chest Pain
HTN
Heart Attack, if yes, when?	Date of Heart Attack
Pacemaker
Dizziness

Neurological

Seizures
Stroke
Alzheimer's

Psychiatric

Anxiety
Depression

Past Medical Surgical History and any illness not listed previously. Please include dates.
Allergies (please list all)
Are any of your medical conditions bothering you today? If so please explain?
Patient Signature	Date