Patient Medical History Questionnaire This form will help us gather information to better assess your eye health. Full NameStreet, City and Zip CodePhone or CellWork PhoneBirth Date MM slash DD slash YYYY Last Eye Exam MM slash DD slash YYYY Parents Name or SpouseWhom may we thank for referring you to our office?MEDICAL HISTORYName of Medical DoctorLast Medical Exam: MM slash DD slash YYYY Do you have any allergies to medications? yes no If yes, explainList any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies):List all major injuries, surgeries and/or hospitalizations you have had:Select any of these that you have had: Crossed Eyes Prominent Eyes Cataracts Lazy Eye Glaucoma Eye Infection Drooping Eyelid Retinal Disease Eye Injury Are you pregnant and/or nursing? yes no Do you wear glasses? yes no If yes, how old is your present pair of lenses?Do you wear contact lenses? yes no If yes, how old is your present pair of lenses?Type of contact lenses?RigidSoftExtended WearOtherAre they comfortable? yes no FAMILY HISTORYPlease note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:Disease/Condition Blindness Cataract Crossed Eyes Glaucoma Macular Degeneration Retinal Detachment/Disease Arthritis Cancer Diabetes Heart Disease High Blood Pressure Kidney Disease Lupus Thyroid Disease Other If any checked above, please list relative associated with that condition/diseaseSOCIAL HISTORYThis information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.I would prefer to discuss my Social History information directly with my doctor: yes no Do you Drive? yes no Do you have visual difficulty when driving? yes no If yes, please describeDo you use tobacco products? yes no If yes, what type, how much & how long?Do you drink alcohol? yes no If yes, what type, how much & how long?Do you use illegal drugs? yes no If yes, what type, how much & how long?Disease/Condition Gonorrhrea Hepatitis HIV Syphilis REVIEW OF SYSTEMSDo you currently, or have you ever had any problem in the following areas:CONSTITUTIONAL SYSTEM - Fever, Weight Loss/Gainnot sureyesnoINTEGUMENTARY - Skinnot sureyesnoNEUROLOGICAL - Headachesnot sureyesnoMigrainesnot sureyesnoSeizuresnot sureyesnoEYES - Loss of Visionnot sureyesnoBlurred Visionnot sureyesnoDistorted Vision or Halosnot sureyesnoLoss of Side Visionnot sureyesnoDouble Visionnot sureyesnoDrynessnot sureyesnoMucous Dischargenot sureyesnoRednessnot sureyesnoSandy or Gritty Feelingnot sureyesnoItchingnot sureyesnoBurningnot sureyesnoForeign Body Sensationnot sureyesnoExcess Tearing or Wateringnot sureyesnoGlare or Light Sensitivitynot sureyesnoEye Pain or Sorenessnot sureyesnoChronic Infection of Eye or Lidnot sureyesnoSties or Chalazionnot sureyesnoFlashes or Floaters in Visionnot sureyesnoTired Eyesnot sureyesnoENDOCRINE - Thyroid or Other Glandsnot sureyesnoEARS, NOSE, MOUTH OR THROAT - Allergies or Hay Fevernot sureyesnoSinus Congestionnot sureyesnoRunny Nosenot sureyesnoPost Nasal Dripnot sureyesnoDry Throat or Mouthnot sureyesnoChronic Coughnot sureyesnoRESPIRATORY - Asthmanot sureyesnoChronic Bronchitisnot sureyesnoEmphysemanot sureyesnoVASCULAR AND CARDIOVASCULAR - Diabetesnot sureyesnoHeart Painnot sureyesnoHigh Blood Pressurenot sureyesnoVascular Diseasenot sureyesnoGASTROINTESTINAL - Diarrheanot sureyesnoConstipationnot sureyesnoGENITOURINARY - Genitals or Kidney or Bladdernot sureyesnoBONES, JOINTS & MUSCLES - Rheumatoid Arthritisnot sureyesnoMuscle Painnot sureyesnoJoint Painnot sureyesnoLYMPHATIC AND HEMATOLOGIC - Anemianot sureyesnoBleeding Problemsnot sureyesnoAllergic or Immunologicnot sureyesnoPSYCHIATRICnot sureyesnoIf you answered YES to any of the above or have a condition not listed, please explain & list medicationsCAPTCHAEmailThis field is for validation purposes and should be left unchanged.
