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Patient Social and Family History
Patient portal
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Patient Social and Family History
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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
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Other
Race
White
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Asian
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Ethnicity
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Mexican
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Smoking History
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Quit
Currently Smoke
Family History
Check all that apply and explain if related to self or relative
Macular Degeneration
Please select an option
NO
YES
Retinal Detachment
Please select an option
NO
YES
Glaucoma
Please select an option
NO
YES
Diabetes
Please select an option
NO
YES
Ocular History
Have you had Lasik?
Please select an option
NO
YES
Do you wear Contact Lenses?
Please select an option
NO
YES
Have you worn contacts in the past?
Please select an option
NO
YES
Do you have macular degeneration?
Please select an option
NO
YES
Have you had cataract surgery?
Please select an option
NO
YES
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
Please select an option
NO
YES
Double Vision
Please select an option
NO
YES
Floaters
Please select an option
NO
YES
Dry Eyes
Please select an option
NO
YES
Decreased Vision
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NO
YES
Excessive Tears
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NO
YES
Sandy Feeling
Please select an option
NO
YES
Musculoskeletal
Joint Pain
Please select an option
NO
YES
Stiffness
Please select an option
NO
YES
Arthritis
Please select an option
NO
YES
Ear, Nose, Throat
Hard of Hearing
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NO
YES
Ringing in Ears
Please select an option
NO
YES
Vertigo
Please select an option
NO
YES
Gastrointestinal Problems
Stomach
Please select an option
NO
YES
Liver
Please select an option
NO
YES
Blood/Lymph
Easy Bruising
Please select an option
NO
YES
Blood Thinners
Please select an option
NO
YES
Anemia
Please select an option
NO
YES
Kidney/Urinary Problems
Prostate
Please select an option
NO
YES
Bladder
Please select an option
NO
YES
Kidney
Please select an option
NO
YES
Cardiovascular
Chest Pain
Please select an option
NO
YES
HTN
Please select an option
NO
YES
Heart Attack, if yes, when?
Please select an option
NO
YES
Date of Heart Attack
Pacemaker
Please select an option
NO
YES
Dizziness
Please select an option
NO
YES
Neurological
Seizures
Please select an option
NO
YES
Stroke
Please select an option
NO
YES
Alzheimer's
Please select an option
NO
YES
Psychiatric
Anxiety
Please select an option
NO
YES
Depression
Please select an option
NO
YES
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
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