Medical History Questionnaire

Medical History Questionnaire
Please fill out in blue or black ink only.
Today's Date:

MonthDayYear
Date
Patient Name:
Date of Birth

MonthDayYear
Date
Patient Phone #:
Name of Medical Doctor
Date of Last Exam

MonthDayYear
Date
Doctor's Phone:
Name of Last Eye Doctor
Date of Last Exam:

MonthDayYear
Date
Eye Doctor's Phone:
Fax Number:
Guardian's Name (if applicable):
Guardian's Phone:
MEDICAL HISTORY
Do you have allergies to any medications:

NoYes
If yes, explain:
List any medications you take (including pills, creams, drops, contraceptives, aspirin, over the counter medications, and remedies)
List all major injuries, surgeries, and/or hospitalizations you have had:
List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections or eye injury:
Are you pregnant or nursing?

NoYes
If yes, when is your due date?

MonthDayYear
Date
Do you wear glasses?

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

NoYes
If yes, how old is your present pair of lenses?
Type of contacts:

RigidSoftExtended WearOther
Are they comfortable?

NoYes
Wearing schedule

Daily2-weekMonthly
Current brand and prescription
Family History
Please note any family history (parents, grandparents, siblings, children; living or deceased) of the following conditions:
Blindness

NoYes?
Relationship to you
Cataracts

NoYes?
Relationship to you
Crossed Eyes

NoYes?
Relationship to you
Glaucoma

NoYes?
Relationship to you
Macular Degeneration

NoYes?
Relationship to you
Retinal Detachment/Disease

NoYes?
Relationship to you
Arthritis

NoYes?
Relationship to you
Cancer

NoYes?
Relationship to you/Type
Diabetes

NoYes?
Relationship to you
Heart Disease

NoYes?
Relationship to you
High Blood Pressure

NoYes?
Relationship to you
Kidney Disease

NoYes?
Relationship to you
Lupus

NoYes?
Relationship to you
Thyroid Disease

NoYes?
Relationship to you
Other

NoYes?
Disease/condition and Relationship to you
SOCIAL HISTORY This 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 the doctor.

Check box
Do you drive?

NoYes
If yes, do you have visual difficulty when driving?

NoYes
If yes, please describe:
Do you use tobacco products?

NoYes
If yes, type/amount/how long?
Do you drink alcohol?

NoYes
If yes, type/amount/how long?
Do you use illegal drugs

NoYes
If yes, type/amount/how long?
Have you ever been exposed to or infected with(check all that apply , if any):

GonorrheaHepatitisHIVSyphilis
REVIEW OF SYSTEMS: Do you currently or have you ever had any problems in the following areas?
CONSTITUTIONAL
Fever

NoYes?
Recent weight loss/gain

NoYes?
INTEGUMENTARY(SKIN)
Rash/Itching/New growth

NoYes?
NEUROLOGICAL
Headaches

NoYes?
Migraines

NoYes?
Dizziness/Lightheadedness

NoYes?
Seizures

NoYes?
Numbness/Tingling Sensation

NoYes?
EYES
Loss of Vision

NoYes?
Blurred Distance Vision

NoYes?
Blurred Near Vision

NoYes?
Distorted Vision/Halos

NoYes?
Loss of side vision

NoYes?
Double vision

NoYes?
Night vision problems

NoYes?
Color vision problems

NoYes?
Dryness

NoYes?
Mucous discharge

NoYes?
Redness

NoYes?
Foreign body sensation

NoYes?
Sandy or gritty feeling

NoYes?
Itching

NoYes?
Burning

NoYes?
Excess tearing/watering

NoYes?
Glare/light sensitivity

NoYes?
Eye pain or soreness

NoYes?
Chronic infection of eye or lid

NoYes?
Sties or Chalazion

NoYes?
Flashes/floater in vision

NoYes?
Tired eyes

NoYes?
ENDOCRINE
Thyroid problems

NoYes?
Other gland problems

NoYes?
EARS, NOSE, MOUTH, THROAT
Allergies

NoYes?
Sinus congestion

NoYes?
Runny nose

NoYes?
Post nasal drip

NoYes?
Chronic cough

NoYes?
Dry throat/mouth

NoYes?
RESPIRATORY
Asthma Chronic Bronchitis Emphysema
Asthma

NoYes?
Chronic Bronchitis

NoYes?
Emphysema

NoYes?
COPD

NoYes?
VASCULAR/CARDIOVASCULAR
Diabetes

NoYes?
Heart/chest pains

NoYes?
High blood pressure

NoYes?
Vascular Disease

NoYes?
GASTROINTESTINAL
Diarrhea

NoYes?
Constipation

NoYes?
GENITOURINARY
Genitals/Kidney/Bladder

NoYes?
BONES/JOINTS/HEMATOLOGIC
Rheumatoid Arthritis

NoYes?
Muscle Pain/Weakness

NoYes?
Joint Pain/Weakness

NoYes?
LYMPHATIC/HEMATOLOGIC
Anemia

NoYes?
Bleeding/Bruising Problems

NoYes?
ALLERGIC/IMMUNOLOGIC
Eczema

NoYes?
Immunological Disease

NoYes?
PSYCHIATRIC
Memory Loss/Confusion

NoYes?
Nervousness/Panic Attacks

NoYes?
If you answered YES to any of the above or have a condition not listed, please explain & list medications:
Doctor's Signature Date
Should be Empty:

Medical History Questionnaire

MEDICAL HISTORY

Family History