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Health History Form

Health History Form

Please complete this form, press submit, and then return to our online forms page to complete the rest of your forms.

Health History

First Name *

Middle Name

Last Name *

Date *

Date of Birth *

Date of Last Eye Exam

Email Address

Do you have an allergy to latex? *YESNO

Do you have allergies to any medication? *YESNO

If YES, list the medications:

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

List any surgeries you have had (including eye surgeries):

Do you have any problems in the following areas?

Poor Vision *YESNO

Eye Pain *YESNO

Dry Eyes *YESNO

HIV/AIDS *YESNO

Fever *YESNO

Unusual Weight Gain/Loss *YESNO

Tiredness *YESNO

Congestion *YESNO

Wheezing *YESNO

Shortness of Breath *YESNO

Diarrhea / Constipation *YESNO

Ulcers / Hernia *YESNO

High Blood Pressure *YESNO

Heart Problems *YESNO

Skin Rash *YESNO

Skin Growths *YESNO

Pregnant *YESNO

Nursing *YESNO

Muscle/Bone/Joint Swelling *YESNO

Joint Pain *YESNO

Arthritis *YESNO

Hepatitis C *YESNO

Headache *YESNO

Seizures *YESNO

Paralysis *YESNO

Frequent Urination *YESNO

Painful Urination *YESNO

Impotence *YESNO

Diabetes *YESNO

Thyroid *YESNO

Bleeding Disorders *YESNO

High Cholesterol *YESNO

Anxiety *YESNO

Depression *YESNO

Prostate *YESNO

Family HistoryHas any of your immediate family members had these diseases? (father, mother, siblings, grandparents)

Blindness *

Cataract *

Glaucoma *

Diabetes *

Hypertension *

Heart Disease *

Stroke *

Cancer *

Thyroid Disease *

Arthritis *

Other Heritable Disease *

Unknown or Adopted without knowledge of family history *

Social History

Does your vision limit activities of daily living (driving, reading, work, etc.)? *YESNO

Have you ever had a blood transfusion? *YESNO

Do you drink alcohol? *YESNO

If YES, how much?

Do you smoke? *YESNO

If YES, how much?

If YES, for how many years?

Vaccinations

Flu *YESNO

Date *

COVID-19 *YESNO

Date of Most Recent Booster *

Pneumonia *YESNO

Date *

If you have any additional information you would like to add regarding medications you currently take, allergies to any medications, major illnesses, or any surgeries you may have had, please specify in the box below:

Please do not fill in this field.

WE ARE A LEADING MULTI-DISCIPLINARY REFERRAL EYE CARE CENTER SPECIALIZING IN CATARACTS, REFRACTIVE SERVICES, AND OTHER OCULAR DISEASES

Location

3025 Hamaker Court
Suite 101
Fairfax, VA 22031
Get Directions

Contact Us

Phone: 703-876-9630
Fax: 703-876-0163

Appointment Hours

Monday-Friday

8:30 A.M. to 4:30 P.M.

(closed for lunch 11:30-12:30 P.M.)

Phone Hours

Monday-Friday

9:00-11:30 A.M. and 1:00-4:30 P.M.

Copyright @ Capital Eye Consultants