life saver Medical History Form Date MM slash DD slash YYYY Patient's Name First Last Date of Birth MM slash DD slash YYYY Date of last eye exam MM slash DD slash YYYY Personal Medical Information: Allergic/Immunologic Genitourinary Nervous System Mental Blood/Lymph/Cancer Headaches/Migraines Respiratory Cardiovascular High blood pressure Skin Diabetes High Cholesterol Ear/Nose/Throat Musculoskeletal/Arthritis Endocrine (Glands) Gastrointestinal Surgeries Do you have problems with any of these systems? If Yes, please check box.If you have had surgeries, what type & when? Are You In Good Health Yes No Do You Take Medications? Yes No List MedicationName First Last How Often Any allergic reactions to medications or other substances? Yes No if Yes Please List Name of general physician PhoneDo you have any of the following? Blurred Vision Eye Surgeries Wear Contacts Cataracts Glaucoma Wear Glasses Dry Eyes Macular Degen. Eye Injuries Retinal Detachment Others If Yes, please check box.Other Please ExplainPlease check Yes or No, if you smoke? Yes No How Much Please check Yes or No, if you Drink? Yes No How Much? Please check Yes or No, if you Drink? Yes No Do you have family history of any of the following? Cataracts High blood pressure Retinal Detachment Diabetes High Cholesterol Glaucoma Macular Degen Others If Yes, please check box.Please explain any boxes you have checked Please sign below that you have reviewed all information above and it is correct to the best of your knowledge.Date MM slash DD slash YYYY
