Elite Eye Care & Optical - Paragould-Opt Medical History

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1515 W Kingshighway Unit B
Paragould, AR 72450
(870) 215-0000

Opt Medical History Patient Details

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First Name*

Last Name*

Middle Name

Date of Birth*

Address*

City*

State*

Zip*

Gender*

Marital Status*

Driving License Number

Opt Medical History Contact Information

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Email*

Home Phone Number

Cell Phone Number*

Work Phone Number

Work Extension Number

Opt Medical History Medical History

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Do you currently have any problems in the following areas, please check the box and provide information.

Diabetes (Type 1)
Diabetes (Type 2)
High Blood Pressure

Cancer
Ears/Eyes/Nose Throat (Stuffy nose, ear ache, etc)
Fever
Weight loss
Respiratory (congestion, wheezing. etc.)
Gastrointestinal (stomach upset ,diarrhea, constipation, etc.)
Genital, Kidney, Bladder (painful urination, frequent urination, impotence, etc.)
Muscles, Bones, Joints (Joint pain, stiffness, swelling, cramps, etc.)
Skin(pimples, warts, growths, rash, etc.)
Neurological (numbness, headache, etc.)
Psychiatric (anxiety, depression, insomania)
Endocrine (diabetes, hypothyroid, etc.)
Blood/Lymph (cholesterolemia, anemia, etc.)
Allergic/Immunologic (sneezing, swelling, redness, itching, hives, etc.)

List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, etc.)or injuries (concussion, etc.)

List any surgeries you have had (cataract, tonsillectomy, appendectomy)

Please describe any other health issues?

Do you currently take any medications (prescription or over-the-counter) ?

Yes
No

Please list here

Do you have any allergies to any medications

Yes
No

Please list here

Do you use cigarettes or any tobacco products

Yes
No

Your Primary Care Doctor

Date of last visit

Date of Last Eye Exam

Opt Medical History EYE History

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Do you currently have any problems in the following areas, please check the box and provide information.

Loss of Vision
Blurred Vision
Fluctuating Vision
Distorted Vision (halos)
Glare or light sensitivity
Loss of side Vision
Double vision
Dryness
Mucous discharge
Redness
Sandy or gritty feeling
Itching
Burning
Foreign body sensation
Excess tearing or watering
Eye pain or soreness
Infection of eye or lid
Tired eyes
Crossed eyes, lazy eye
Drooping eyelid

Please describe any problems with your eyes for which you are seeking treatment today

Do you have any other eye conditions or problems?

Yes
No

If so, describe

Have you had a serious eye injury or eye surgery (including laser vision correction)? If yes, please describe

Date

Are you using any eye drops (prescription or over the counter)? Please list

Are you interested in the following

new glasses
contact lenses
Vision correction surgery

Do you wear glasses

Yes
No

Do you wear contact lenses

Yes
No

If Yes

Soft
Rigid

SIGNATURE (Patient Signature)*

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Opt Medical History Family History

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Blindness

Yes
No

Relationship To Patient*

Glaucoma

Yes
No

Relationship To Patient*

Arthritis

Yes
No

Relationship To Patient*

Cancer

Yes
No

Relationship To Patient*

Diabetes

Yes
No

Relationship To Patient*

Heart Disease or High Blood Pressure

Yes
No

Relationship To Patient

Kidney Disease

Yes
No

Relationship To Patient*

Lupus

Yes
No

Relationship To Patient*

Stroke

Yes
No

Relationship To Patient*

Thyroid Disease

Yes
No

Relationship To Patient*

Other

Yes
No

Relationship To Patient*

Please Specify(Other)

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