Flanders Family Eye Care Dr. Jeanine Jacco Labrada
240 Route 206 South Unit 5 Dr. Richard Corney
Flanders, NJ 07836
(973) 252-1119 Medical History Questionnaire
Name: _ Name:___________________________________________________ Today’s Date: _____/_____/_____
Address: ________________________________________________ Phone: _______________________________
Town:_____________________________________________________________________ Work Phone: __________________________
Guardian (If Applicable): __________________________________ Occupation: ___________________________
Birth Date: _____/_____/_____ Social Security #: ______/_____/______ Last Eye Exam: _____/_____/_____
Name of Medical Doctor: __________________________________ Last Medical Exam: _____/_____/_____
Marital Status: ___Single ___Married ___Divorced ___Widowed Sex: ___Male ___Female
Notification Preference: ___Phone ___Email Email address: _______________________________
Medical History
Do you have any allergies to medications? ___ no ___ yes If yes, explain: ________________________________________________
______________________________________________________________________________________________________________
List any medications you take (including oral contraceptives, aspirin, over the counter medications, and home remedies):
_______________________________________________________________________________________________________________
List any major injuries, surgeries and / or hospitalizations you have had: ______________________________________________________
________________________________________________________________________________________________________________
List any of the following that you have had: Crossed eyes, lazy eyes, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts,
eye infections or eye injury: _________________________________________________________________________________________
Are you pregnant or nursing? ___ no ___ yes
Do you wear glasses? ___ no ___ yes If yes, how old is your present pair of lenses? __________________________________
Do you wear contact lenses ___ no ___ yes If yes, how old is your present pair of lenses? __________________________________
Type of contact lenses: ____ Rigid ____ Soft ____ Extended Wear ____ Other Are they comfortable? ___ no ___ yes
Family History
Please note any family history (parents, grandparents, siblings, children, living or deceased) for the following conditions:
DISEASE/CONDITION NO YES ? RELATIONSHIP TO YOU
Blindness ____ ____ ____ ________________________
Cataract ____ ____ ____ ________________________
Crossed Eyes ____ ____ ____ ________________________
Glaucoma ____ ____ ____ ________________________
Macular Degeneration ____ ____ ____ ________________________
Retinal Detachment / Disease ____ ____ ____ ________________________
Arthritis ____ ____ ____ ________________________
Diabetes ____ ____ ____ ________________________
Cancer ____ ____ ____ ________________________
Heart Disease ____ ____ ____ ________________________
High Blood Pressure ____ ____ ____ ________________________
Kidney Disease ____ ____ ____ ________________________
Lupus ____ ____ ____ ________________________
Thyroid Disease ____ ____ ____ ________________________
Other ____ ____ ____ ________________________
* Please turn this form over and complete side two *
Social History This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
____ Yes, I would prefer to discuss my Social History information directly with my doctor. (Check Box)
Do you drive? ___ no ___ yes If yes, do you have difficulty when driving? ___ no ___ yes If yes, please describe:
____________________________________________________________________________________________________________
Do you use tobacco products? ___ no ___ yes If yes, type/ amount/ how long: ______________________________________________
Do you drink alcohol? ___ no ___ yes If yes, type/ amount/ how long: ______________________________________________
Do you use illegal drugs? ___ no ___ yes If yes, type/ amount/ how long: ______________________________________________
Have you ever been exposed to or infected with: ____ Gonorrhea ____ Hepatitis ____ HIV ____ Syphilis
Review of Systems
Do you currently, or have you ever had any problems with the following areas:
SYSTEM NO YES ? NO YES ?
Constitutional Ears, Nose, Mouth, Throat
Fever, Weight Loss/ Gain ____ ____ ____ Allergies/ Hay Fever ____ ____ ____
Integumentary (skin) ____ ____ ____ Sinus Congestion ____ ____ ____
Neurological Runny Nose ____ ____ ____
Headaches ____ ____ ____ Post-Nasal Drip ____ ____ ____
Migraines ____ ____ ____ Chronic Cough ____ ____ ____
Seizures ____ ____ ____ Dry Throat/ Mouth ____ ____ ____
Eyes Respiratory
Loss of vision ____ ____ ____ Asthma ____ ____ ____
Blurred Vision ____ ____ ____ Chronic Bronchitis ____ ____ ____
Distorted Vision/ Halos ____ ____ ____ Emphysema ____ ____ ____
Loss of Side Vision ____ ____ ____ Vascular / Cardiovascular
Double Vision ____ ____ ____ Diabetes ____ ____ ____
Dryness ____ ____ ____ Heart Pain ____ ____ ____
Mucous Discharge ____ ____ ____ High Blood Pressure ____ ____ ____
Redness ____ ____ ____ Vascular Disease ____ ____ ____
Sandy or Gritty Feeling ____ ____ ____ Gastrointestinal
Itching ____ ____ ____ Diarrhea ____ ____ ____
Burning ____ ____ ____ Constipation ____ ____ ____
Foreign Body Sensation ____ ____ ____ Genitourinary
Excess Tearing / Watering ____ ____ ____ Genitals/Kidney/Bladder ____ ____ ____
Glare/ Light Sensitivity ____ ____ ____ Bones/ Joints/ Muscles
Eye Pain or Soreness ____ ____ ____ Rheumatoid Arthritis ____ ____ ____
Chronic Infection of Eye or Lid ____ ____ ____ Muscle Pain ____ ____ ____
Sties or Chalazion ____ ____ ____ Joint Pain ____ ____ ____
Flashes / Floaters in Vision ____ ____ ____ Lymphatic / Hematologic
Tired Eyes ____ ____ ____ Anemia ____ ____ ____
Endocrine Bleeding Problems ____ ____ ____
Thyroid/ Other Glands ____ ____ ____ Allergic / Immunologic ____ ____ ____
Psychiatric ____ ____ ____
If you answered YES to any of the above or have a condition not listed, please explain and list medications:
_____________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
____________________________________________________________ __________________________________
Doctor’s Signature Date