Ocular Health History

Patient Name: Date:

Email Address: Phone No.
Address:
Job Position: Employer:
Start Date: Years:
Screen Time Hours per Day: Distance from Screen:
Miles Driven per Day: Day or Night:
Glare Problems while Driving: ¨ Yes ¨ No Night Vision Problems: ¨ Yes ¨ No
Glasses: ¨ Yes ¨ No Year Acquired:
Type: ¨ Full-time ¨ Occupational ¨ Reading ¨ Distance ¨ Bifocal ¨ Safety ¨ Athletics
Sunglasses: ¨ Yes ¨ No Prescription: ¨ Yes ¨ No
Contacts: ¨ Yes ¨ No Willing to Try Contacts: ¨ Yes ¨ No
Medications:
Allergies:
Pregnant: ¨ Yes ¨ No Nursing: ¨ Yes ¨ No
Alcohol Use: ¨ Never ¨ Occasionally ¨ Monthly ¨ Weekly ¨ Daily ¨ 4+ per Day
Smoking: ¨ Never ¨ Occasionally ¨ 1 per Day ¨ 1 Pack per Day ¨ 2+ Packs per Day
Illegal Drug Use: ¨ Never ¨ Occasionally ¨ Monthly ¨ Weekly ¨ Daily
Exercise: ¨ Never ¨ Occasionally ¨ Weekly ¨ 2-3 Times per Week ¨ Daily

My History My Family History

Amblyopia ¨ Yes ¨ No Amblyopia ¨ Yes ¨ No
Blindness ¨ Yes ¨ No Blindness ¨ Yes ¨ No
Blurred Vision ¨ Yes ¨ No Blurred Vision ¨ Yes ¨ No
Burning Sensation ¨ Yes ¨ No Burning Sensation ¨ Yes ¨ No
Cataracts ¨ Yes ¨ No Cataracts ¨ Yes ¨ No
Color Blindness ¨ Yes ¨ No Color Blindness ¨ Yes ¨ No
Diabetic Retinopathy ¨ Yes ¨ No Diabetic Retinopathy ¨ Yes ¨ No
Distorted Vision ¨ Yes ¨ No Distorted Vision ¨ Yes ¨ No
Dry Eyes ¨ Yes ¨ No Dry Eyes ¨ Yes ¨ No
Epiphora ¨ Yes ¨ No Epiphora ¨ Yes ¨ No
Glaucoma ¨ Yes ¨ No Glaucoma ¨ Yes ¨ No
Headaches ¨ Yes ¨ No Headaches ¨ Yes ¨ No
Infection ¨ Yes ¨ No Infection ¨ Yes ¨ No
Injury ¨ Yes ¨ No Injury ¨ Yes ¨ No
Itching ¨ Yes ¨ No Itching ¨ Yes ¨ No
Light Sensitivity ¨ Yes ¨ No Light Sensitivity ¨ Yes ¨ No
Loss of Vision ¨ Yes ¨ No Loss of Vision ¨ Yes ¨ No
Mucous Discharge ¨ Yes ¨ No Mucous Discharge ¨ Yes ¨ No
Redness ¨ Yes ¨ No Redness ¨ Yes ¨ No
Retinal Detachment ¨ Yes ¨ No Retinal Detachment ¨ Yes ¨ No
Strabismus ¨ Yes ¨ No Strabismus ¨ Yes ¨ No
Swelling ¨ Yes ¨ No Swelling ¨ Yes ¨ No
Tired/Sore ¨ Yes ¨ No Tired/Sore ¨ Yes ¨ No
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