drgording.com-Medical History Questionnaire

Medical History Questionnaire
Name*
Today’s Date

MonthDayYear
Reason for Today’s Visit (Please check all that apply.)

Eye HealthContact LensesGlassesVision ProblemEye InfectionNew ConditionExisting ConditionSurgery Consultation
Please Explain:
Dilation: For an important and thorough view of the back of the eye, we instill drops which cause your pupils to enlarge. The drops require about 30 minutes to take effect. Afterwards, you will be sensitive to bright lights and you may have difficulty focusing on close objects. The effect may last for 4 hours.
Do you wish to be dilated today?

YesNoNeed more information
Retinal Photography: The doctor would like to take a picture of the back of the eye. These images help us to identify, compare, and monitor your internal eye health. They are used as a baseline to compare any changes to your eye health on a yearly basis, and identify problems due to diabetes, glaucoma, high blood pressure, and hardening of the arteries. This test is highly recommended and is available for an additional fee of $45.00 .
Would you like these pictures to be taken and included in your permanent records?

YesNoNeed more information
Medical History
Do you take any medications?

YesNo
(If yes, please include oral contraceptives, over the counter medications, aspirin, and supplements.)
Do you have any allergies to medications?

YesNo
If yes, please explain:
List all major injuries, surgeries,and medical conditions
Check any of the following that you have had

dry eyescataractsglaucomacrossed eyesfloatersretinal disease/detachmentmacular degenerationeye injuryeye surgery
Are you pregnant or nursing?

YesNo
Do you wear glasses?

YesNo
If yes, how old is your present pair?
Do you wear contact lenses?

YesNo
If yes, how old is your present pair?
Type of contact lenses

SoftRifit
Are they comfortable?

YesNo
Family History:
Please notate parents, grandparents, sibling, or children for the following conditions.

Disease/Condition

	Yes	No	?	Relationship to you
Blindness
Cataract
Crossed Eyes
Glaucoma
Arthritis
Macular Degeneration
Retinal Disease
Cancer
Diabetes
Heart Disease
High Blood Pressure
Thyroid Disease
Autoimmune Disease
Other

	Yes	No	?
Fever
Weight gain
Weight loss

	Yes	NO	?
Headaches
Migraines
Seizures

	Yes	No	?
Loss of Vision
Blurred Vision
Distorted Vision/Halos
Loss of Side Vision
Double Vision
Dryness
Mucous Discharge
Redness
Sandy or Gritty Feeling
Itching
Burning
Foreign Body Sensation
Execess Tearing/Watering
Glare/Light Sensitivity
Eye Pain or Soreness
Chronic Infection,Eye or Lid
Sties or Chalazion
Flashes/Floaters in Vision
Tired Eyes

	Yes	No	?
Allergies/Hay Fever
Sinus Congestion
Runny Nose
Post Nasal Drip
Chronic Cough
Dry Throat/Mouth

	Yes	No	?
Asthma
Chronic Bronchitis
Emphysema

	Yes	No	?
Diarrhea
Constipation

	Yes	No	?
Anemia
Bleeding Problems