Patient Case History Form - Dr. Clayton Y. Gushiken

Name *

First

Last

Phone *

Email *

What is the main reason for today’s visit?

BACKGROUND INFORMATION

1. Are you having any special eye or vision problems at this time?

Yes
No

If YES, please explain:

2. What is your present occupation?

3. How do you use your eyes while at work?

4. Do you have any hobbies or sports that have special vision requirements?

Yes
No

If YES, please explain:

MEDICAL HISTORY

1. Who is your personal physician?

2. Physician's Phone Number:

3. When did you have your last complete physical examination?

4. Were any medical problems discovered at that examination?

Yes
No

If YES, please explain:

5. Are you being treated for any medical condition at this time?

Yes
No

If YES, for what condition(s)?:

6. Do you smoke any tobacco products?

Yes
No

If YES, what products and how much per day?

7. Do you have any of the following medical conditions?

Type of Cancer:

Hearing Problems: On which side?

Other: Please describe:

8. Are you currently taking any medications?

Yes
No

If YES, please list medication(s): Name, Dosage, and for what Condition:

9. Has there been any change in your medication dosage in the past six (6) months?

Yes
No

If so, please explain:

10. If FEMALE: Are you taking birth control pills?

Yes
No

11. If FEMALE: Are you pregnant at this time?

Yes
No

If YES, how many months?

12. Is there any family history of the following medical conditions:

a. Cataracts: If YES, family relationship:

b. Diabetes: If YES, family relationship:

c. Glaucoma: If YES, family relationship:

d. Heart Disease: If YES, family relationship:

e. High Blood Pressure: If YES, family relationship:

f. Stroke: If YES, family relationship:

EYE / OCULAR HISTORY

1. When was your last eye exam?

2. What was your previous eye doctor?

3. Have you ever worn glasses?

Yes
No

4. For how many years?

5. How many changes?

6. When were you told to wear your glasses? (All of the time, Distance Only, Near Only)

All of the time
Distance Only
Near Only

7. When do you wear your present glasses?

All of the time
Distance Only
Near Only

8. How long have you had your present glasses?

9. Do you see well through them?

Yes
No

10. Have you ever worn contact lenses?

Yes
No

If YES, what type of lenses?

11. When did you first start wearing contacts?

12. When did you stop wearing contacts?

13. Who fitted you with your contact lenses?

14. Are you bothered by any of the following?

If you wear glasses or contact lenses, please answer these questions assuming that you are wearing them.

15. Have you had any illness or accident that affected your eyes?

Yes
No

If YES, explain:

16. Have you had any eye/ocular surgery?

Yes
No

If YES, explain:

17. Have you had any refractive surgery (LASIK, PRK, RK)?

Yes
No

If YES, explain:

18. Have you ever had any of the following eye/ocular problems?

19. Are you presently taking any medications for these eye/ocular problems?

Yes
No

If YES, please list below: Medication, Dosage, for what Condition:

20. Do you use eye cosmetics (Eyeliner, Mascara, Eye Shadow)?

Yes
No

21. If YES, are they water-base or oil base?

HEADACHE HISTORY

1. How frequently do you have headaches?

2. Where are they located?

3. On which side of the head do you usually have your headaches (Right, Left, Both)?

4. Please describe the type of pain you feel?

5. What do you think may be causing the headaches?

6. When during the day do your headaches usually begin?

(Wake up with it, Late morning, Early Afternoon, Late Afternoon, Early Evening)?

7. How long do your headaches usually last?

8. What do you usually do to relieve your headaches?

9. Do your headaches affect your ability to see?

Yes
No

If YES, how:

10. Are your headaches so severe that you cannot continue to do anything?

ADDITIONAL INFORMATION YOU FEEL MIGHT BE HELPFUL: