Robert N. Brems, M.D. and Dana D. Bates, O.D.

Patient Medical History

Patient name: ______________________________________________________

Reason for visit: (circle one)   Routine Exam    Consult    Eye Problem

Do you presently wear glasses? (YES) (NO)
If yes, are they for: Distance_____ Reading_____ Bifocals_____ Trifocals_____

Do you presently wear contact lenses? (YES) (NO)
If yes, the brand name is: ________________________B.C._______DIA_______
RX (power) for Right Eye__________________Left Eye____________________
Are you interested in Laser Corrective Surgery? (YES) (NO)

Are you allergic to any medications? (YES) (NO)
If yes, please list:____________________________________________________

Do you take any daily medications? (YES) (NO)
If yes, please list:____________________________________________________ ________________________________________________________________

Have you ever abused alcohol or drugs? (YES) (NO)

Have you ever smoked? (YES) (NO)
If yes, do you currently smoke? (YES) (NO)

Have you ever had:
Arthritis
Cancer
Diabetes
Thyroid Disease
Heart Disease
Heart Attack
Liver Disease
Neurological Disorder
Glaucoma
Eye Muscle Problems


(YES) (NO)
(YES) (NO)
(YES) (NO)
(YES) (NO)
(YES) (NO)
(YES) (NO)
(YES) (NO)
(YES) (NO)
(YES) (NO)
(YES) (NO)

Hepatitis
Kidney Disease
Stroke
High Blood Pressure
Mini-Stroke (TIA)
Lung Disease
O2 (Oxygen) use
Cataracts
Macular Degeneration


(YES) (NO)
(YES) (NO)
(YES) (NO)
(YES) (NO)
(YES) (NO)
(YES) (NO)
(YES) (NO)
(YES) (NO)
(YES) (NO)

If yes to any of these, please explain below: ________________________________________________________________ ________________________________________________________________
Do any members of your immediate family have:
Diabetes
Cataracts
Glaucoma

(YES) (NO)
(YES) (NO)
(YES) (NO)

  Eye Muscle Problems
(ex. lazy eye)
Macular Degeneration

(YES) (NO)

(YES) (NO)
List any previous surgeries or hospitalizations:________________________________