Health History
Patient Full Name
Patient Date of Birth: Ex: 07/13/1969
Primary Care Physician
Date Last Seen Primary Care Physician: Ex: 07/13/2018
Medical/Family History
Please list all your current medications
(include over the counter, vitamins and herbal therapy)
List all major surgeries (Eye Surgery included)
List any allergic reactions to medications or eye drops
Please indicate if any of the conditions apply to you or a family member
(blood relatives only)
Disease/Condition
Yourself
Women - Are you Pregnant
Women - Are you breast feeding
Ever had a blood transfusion
Cataract
Eye Turn
Glaucoma
Macular Degeneration
Retinal Detachment
Disease/Condition
Family Member
Relationship
Blindness
Eye Turn
Glaucoma
Macular Degeneration
Retinal Detachment
Review of Systems:
Please indicate below if you have any problems with the following conditions:
Allergic/Immunologic
Ear, Nose and Throat
None
Lupus (SLE)
Environmental Allergies
Seasonal Allergies
Other:
None
Sinusitis
Upper Respiratory
        Tract Infection
Other:
Gastrointestinal
Skin /Integumentary
None
Colitis
Acid Reflux/Ulcer
Other:
None
Eczema
Rosacea
Psoriasis
Psychiatric
Cardiovascular
None
Depression
Bi-Polar
Schizophrenia
None
High Blood Pressure
Heart Disease
Stroke
Vascular Disease
High Cholesterol
Endocrine/Glands
Respiratory
None
Diabetes
Hormone Dysfunction
Thyroid Dysfunction
Crohn’s Disease
Other:
None
Asthma
Bronchitis
Stroke
Emphysema
Other:
Muscle/Skeletal
Genital/Urinary
None
Arthritis
Fibromyalgia
Ankylosing Spondylitis
Other:
None
Urinary Tract Infection
HIV Positive
Herpes/Chiamydia
Other:
Hematologic/Lymphatic
Neurological
None
Anemia Multiple Sclerosis
Leukemia
Bleeding Disorder
Other:
None
Weight loss/gain
Epilepsy
Tremors
Other:
General Health
Social
None
Fever
Fatigue
Trauma
Weight
Height
Alcohol Consumption
Never Smoked
Current Smoker
Former Smoker

Smoked a day
How many years quit
Non-Prescription Drugs



1016 E. Hebron Pkwy Ste 150
Carrollton, TX 75010
(469) 480-6150
HOURS OF OPERATION    
Monday
9:30am - 6:00pm
Tuesday
9:30am - 6:00pm
Wednesday
9:30am - 6:00pm
Thursday
Closed
Friday
9:30am - 6:00pm
Saturday
Appt. Only
Sunday
Closed
Framed Eyecare 1016 E. Hebron Pkwy Ste 150 Carrollton, TX 75010 Phone: (469) 480-6150

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