Dr. Don Steensma 465 W. Channel Islands Blvd, Port Hueneme, CA 805/486-3585

Name: * Date: *
Last eye examination: Last thorough medical exam:
Do you take any medications?

List on the next page in Section A

Have you had any major illnesses or injuries?

List on the next page in Section B

Have you had any eye surgeries?

List on the next page in Section C

Do you have allergies to any medications?

Do you currently have any problems in the following areas?
If needed continue on next page in Section D
Eyes (poor vision, eye pain, tearing, redness, itching, burning, spots)
N
General/Constitutional (fever, heat stroke, weight loss or gain, unusually tired)
N
Ears, Nose, Throat (hard of hearing, stuffy nose, ear ache, cough, etc.)
N
Cardiovascular (high BP, racing pulse, etc.)
N
Respiratory (congestion, wheezing, shortness of breath, etc.)
N
Gastrointestinal (stomach upset, diarrhea, constipation, ulcers, etc.)
N
Genital, Kidney, Bladder (painful/frequent urination, yellow jaundice, etc.)
N
Females (Are you pregnant? Nursing?)
N
Muscles, Bones, Joints (joint pain, stiffness, swelling, cramps, arthritis, etc)
N
Skin (warts, growths, rash, skin cancer, etc.)
N
Neurological (numbness, headache, seizures, paralysis, etc.)
N
Psychiatric (anxiety, depression, insomnia)
N
Endocrine (diabetes, hypothyroid, etc.)
N
Allergic / Immunologic (sneezing, swelling, redness, itching, hives, lupus, etc.)
N
Has any member of your family had these diseases (check all that apply)? And who?
Macular Degeneration
Glaucoma
Ever have a blood transfusion?


Do you drink alcohol?


Do you use illicit drugs?


Do you smoke?


Does your vision limit any activities of daily living?


Patient signs: *
Doctor signs: ________________________
Section A - Medication List
Medication Why Taken Medicaton Why Taken
Section B - Major Illnesses & Injuries
Section C - Eye Surgery History
Section D - Other Current Health Problems