Patient Medical History Questionnaire

This form will help us gather information to better assess your eye health.

Patient Information


Medical History

NoYes

Crossed EyesLazy EyeDrooping EyelidProminent EyesGlaucomaRetinal DiseaseCataractsEye InfectionEye Injury

NoYes

NoYes

NoYes

NoYes


Family History

Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:

Disease/Condition


Social History

Yes

NoYes

NoYes

NoYes

NoYes

NoYes


Review of Systems

Do you currently, or have you ever had any problem in the following areas:

Constitutional System

Integumentary

Neurological

Eyes

Endocrine

Ears, Nose, Mouth or Throat

Respiratory

Vascular and Cardiovascular

Gastrointestinal

Genitourinary

Bones, Joints & Muscles

Lymphatic and Hematologic

Allergic or Immunologic

Psychiatric