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(956) 200-2020

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Home
About Us
Services
Specialty Services
Skin Care
Eyewear
- Our Collection
- Shop Online
Patient Center
Español
Contact

Health History Form

Patient Name

Date of Birth

Date of last eye exam

Do you have an allergy to latex?

NoYes

Do you have allergies to any medications?

NoYes

List medications you currently take

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

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

Do you have any problems in the following areas?

Eyes

Poor Vision

NoYes

Eye Pain

NoYes

Dry Eyes

NoYes

HIV/AIDS

NoYes

Constitutional

Fever

NoYes

Unusual Weight Gain/Loss

NoYes

Tired

NoYes

Respiratory

Congestion

NoYes

Wheezing

NoYes

Shortness of Breath

NoYes

Gastrointestinal

Diarrhea / Constipation

NoYes

Ulcers / Hernia

NoYes

Cardiovascular

High blood pressure

NoYes

Heart problems

NoYes

Skin

Rash

NoYes

Growths

NoYes

Females Only:

Pregnant

NoYes

Nursing

NoYes

Muscles/Bones/Joints

Swelling

NoYes

Joint Pain

NoYes

Arthritis

NoYes

Hepatitis C

NoYes

Neurologic

Headache

NoYes

Seizures

NoYes

Paralysis

NoYes

Genital/Bladder

Frequent urination

NoYes

Painful urination

NoYes

Impotence

NoYes

Endocrine

Diabetes

NoYes

Thyroid

NoYes

Blood/Lymphatic

Bleeding Disorders

NoYes

High Cholesterol

NoYes

Psychiatric

Anxiety

NoYes

Depression

NoYes

Male Only

Prostate

NoYes

FAMILY HISTORY (Mother, Father, Grandparent, Sibling)

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

SOCIAL HISTORY

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

NoYes

Have you ever had a blood transfusion?

NoYes

Do you drink alcohol?

NoYes

Do you smoke?

NoYes

VACCINATIONS

Flu

NoYes

Date

COVID-19

NoYes

Date

PNEUMONIA

NoYes

PNEUMONIA

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

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All Eyecare Services

We offer a wide variety of eye care services to the McAllen community. Contact us with any questions about our services.

Keep In Touch

For non-urgent questions or to learn more about our services, contact us today!

Contact Information

8001 N. 10th Street Suite 140,
McAllen, TX 78504
(956) 200-2020
(956) 340-4278
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Office Hours

Monday 9:00 AM – 6:00 PM
Tuesday 9:00 AM – 6:00 PM
Wednesday 9:00 AM – 6:00 PM
Thursday 9:00 AM – 6:00 PM
Friday 9:00 AM – 6:00 PM
Saturday Closed
Sunday Closed

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Home
About Us
Services
Specialty Services
Skin Care
Eyewear
- Our Collection
- Shop Online
Patient Center
Español
Contact

Health History Form