Medical History Form Medical History Form Step 1 of 2 50% Dear New Patient, Welcome to Eye Care Associates. We genuinely appreciate you choosing our practice for your eye care needs. Optometrist, Dr. Helaina Boulieris, specializes in pediatric and adult eye care. You'll find that during your comprehensive eye exam we take time to address your needs, provide education and knowledge so you understand your eyes, and display care and compassion when treating any problems. During our comprehensive eye exams we will assess your eyes for the necessity of glasses. Contact lens evaluations are available for an extra fee. We will evaluate for the presence of any ocular disease such as diabetes, lazy eye, macular degeneration, or glaucoma. For our pediatric patients we spend extra time making them feel comfortable and will properly evaluate their complete visual system for any barriers to their academic learning. In addition to comprehensive eye exams, our practice also provides cataract pre and post-op exams, refractive surgery pre and post-op exams, glaucoma management, diabetic care, high-risk medication care, macular degeneration evaluation, amblyopia treatment, and vision therapy. You should let us know if you have any of the previously stated medical conditions when you come in for your appointment so we can schedule a separate visit for the doctor to assess your condition(s) and set up a treatment plan. Also, while in our office you will find we have a large optical with a variety of frames from which to choose. We carry frames in all price ranges from high end to budget-friendly. We are sure you will find a pair you love. To make your visit go as smoothly as possible, please complete the enclosed forms and bring them with you the day of your appointment. Please bring any glasses or contacts you are currently using, an updated medication list, and your insurance information. Should you need to reschedule, a minimum of 24 hours notice is required. There will be a $30 no show fee.We hope that while you're here you feel comfortable and welcome. We encourage you to ask any questions you may have during or after your exam and we always love to hear your feedback on how we are doing. We look forward to seeing you. Please feel free to call us if you have any additional questions prior to your visit. Thank You, The friendly staff at Eye Care Associates Name* First Last Nickname Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Today's Date* MM slash DD slash YYYY Sex at Birth* Male Female Preferred PronounsShe/her/hersHe/him/hisThey/them/theirsSocial Security Number* Race* Caucasian Black or African American Asian American Indian Native Hawaiian or Other Pacific Islander Other Race Unknown Ethnicity* Not Hispanic or Latino Hispanic or Latino Medical HistoryDo you have any allergies to medications?* Yes No If yes, please explain:* Are you currently taking any medications?* Yes No If yes, please explain:* Post Ocular HistoryPlease check any of the following that you have had.* Cataracts Lazy Eye Glaucoma Macular Degeneration Retinal Detachment LASIK Injury Other None If other, please explain:* Do you wear glasses?* Yes No If yes, how old is your current pair?* Do you wear contacts?* Yes No If yes, What is your current pair?* Family Eye HistoryHas anybody in your family been diagnosed with the following?Cataracts* Yes No If yes, what is their relationship to you?* Glaucoma* Yes No If yes, what is their relationship to you?* Macular Degeneration* Yes No If yes, what is their relationship to you?* Crossed Eyes* Yes No If yes, what is their relationship to you?* Retinal Detachment* Yes No If yes, what is their relationship to you?* Cancer* Yes No If yes, what is their relationship to you?* Diabetes* Yes No If yes, what is their relationship to you?* High Blood Pressure* Yes No If yes, what is their relationship to you?* Heart Disease* Yes No If yes, what is their relationship to you?* Thyroid Disease* Yes No If yes, what is their relationship to you?* Other* Social HistoryDo you now or have you ever used tobacco products?* Yes No If yes, type/amount/how long?* Do you now or have you ever drank alcohol?* Yes No If yes, type/amount/how long?* Review of SystemsPlease check the ones you are currently having problems with:Eyes* Loss of Vision Blurred Vision Double Vision Halos/Glare Light Sensitivity Dry Eye Mucous Discharge Redness Sandy or Gritty Feeling Itching Burning Foreign Body Sensation Excess Tearing/Watering Flashes/Floaters Eye Pain or Soreness None Other If other, please explain:* Constitutional* Fatigue Syndrome Cancer Developmental Disabilities None Other If other, please explain:* ENT* Laryngitis Dry Mouth Sinusitis Hearing Loss None Other If other, please explain:* Neurological* Multiple Sclerosis Epilepsy Cerebral Palsy Tumor Migraine None Other If other, please explain:* Psychiatric* Attention Deficit Anxiety Disorder Bipolar Disorder Depression None Other If other, please explain:* Cardiovascular* Stroke/CVA High Blood Pressure Vascular Disease Heart Disease Congestive Heart Failure None Other If other, please explain:* Respiratory* Asthma Bronchitis Cigarette Smoker Sleep Apnea Chronic Obstruction Emphysema None Other If other, please explain:* Gastrointestinal* Chrohn's Ulcer Colotis Acid Reflux Celiacs Disease Other None If other, please explain:* Genitourinary* Kidney Disease Pregnant/Nursing Prostate Disease/Cancer Herpes None Other If other, please explain:* Musculoskeletal* Gout Osteoporosis Arthritis Muscular Dystrophy Fibromyalgia Other None If other, please explain:* Integumentary* Herpes Zoster/Shingles Herpes Simplex/Cold Sores Eczema None Other If other, please explain:* Endocrine* Type 2 Diabetes Type 1 Diabetes Thyroid Dysfunction Hormonal Dysfunction None Other If other, please explain:* Hematological/Lymphatic* Anemia Large Volume Blood Loss High Cholesterol None Other If other, please explain:* Allergic/Immune* Sjogren's Syndrome Lupus Rhumetoid Arthritis Environmental Allergies Drug Allergies None Other If other, please explain:*
