MEDICAL HISTORY QUESTIONNAIRE
Name: __________________________________________ Today’s Date: ____/____/____
Address: __________________________________________ Social Security #: ____/____/____
__________________________________________ Phone: _______________________
Birth Date: ____/____/____ Age : ____ Sex q M q F Last Eye Exam: ____/____/____
Employer/School _____________________________________ Occupation/Grade: ______________
How did you hear of our office? __________________________ Employer/ School Phone: _________
If someone referred you, please indicate name: ______________
May we use your name in thanking this person ? q Yes q No
Medical History
Name of Medical Doctor: ________________________________ Dr.’s Phone: _________________
Last Medical Exam: ____/____/____
Do you have any allergies to medications? q No q Yes If yes, explain: _________________
___________________________________________________________________________________
List 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: _____________________________
___________________________________________________________________________________
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 and/or nursing? q No q Yes
Do you wear glasses? q No q Yes If yes, how old is your present pair of lenses?___________
Do you wear contact lenses? q No q Yes If yes, how old is your present pair of lenses?___________
If no, are you interested in contact lenses? _____________
Type of contact lenses: q Rigid q Soft q Extended Wear q Other Are they comfortable? q No q 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 q q q ________________________________
Cataract q q q ________________________________
Crossed Eyes q q q ________________________________
Glaucoma q q q ________________________________
Macular Degeneration q q q ________________________________
Retinal Detachment/Disease q q q ________________________________
Arthritis q q q ________________________________
Cancer q q q ________________________________
Diabetes q q q ________________________________
Heart Disease q q q ________________________________
High Blood Pressure q q q ________________________________
Kidney Disease q q q ________________________________
Lupus q q q ________________________________
Thyroid Disease q q q ________________________________
Other _______________ q q q ________________________________
* PLEASE TURN THIS FORM OVER AND COMPLETE SIDE TWO *
q Yes, I would prefer to discuss my Social History information directly with my doctor. (Check box)
Do you drive? q No q Yes If yes, do you have visual difficulty when driving? q No q Yes
If yes, please describe: ______________________________________________________________
Do you use tobacco products? q No q Yes If yes, type/amount/how long: ______________
Do you drink alcohol? q No q Yes If yes, type/amount/how long: ______________
Do you use illegal drugs? q No q Yes If yes, type/amount/how long: ______________
Have you ever been exposed to or infected with: q Gonorrhea q Hepatitis q HIV q Syphilis
Review of Systems
Do you currently, or have you ever had any problems in the following areas:
SYSTEM NO YES ? NO YES ?
CONSTITUTIONAL EARS, NOSE, MOUTH, THROAT
Fever, Weight Loss/Gain q q q Allergies/Hay Fever q q q
INTEGUMENTARY (Skin) q q q Sinus Congestion q q q
NEUROLOGICAL Runny Nose q q q
Headaches q q q Post-Nasal Drip q q q
Migraines q q q Chronic Cough q q q
Seizures q q q Dry Throat/Mouth q q q
EYES RESPIRATORY
Loss of Vision q q q Asthma q q q
Blurred Vision q q q Chronic Bronchitis q q q
Distorted Vision/Halos q q q Emphysema q q q
Loss of Side Vision q q q VASCULAR/CARDIOVASCULAR
Double Vision q q q Diabetes q q q
Dryness q q q Heart Pain q q q
Mucous Discharge q q q High Blood Pressure q q q
Redness q q q Vascular Disease q q q
Sandy or Gritty Feeling q q q GASTROINTESTINAL
Itching q q q Diarrhea q q q
Burning q q q Constipation q q q
Foreign Body Sensation q q q GENITOURINARY
Excess Tearing/Watering q q q Genitals/Kidney/Bladder q q q
Glare/Light Sensitivity q q q BONES/JOINTS/MUSCLES
Eye Pain or Soreness q q q Rheumatoid Arthritis q q q
Chronic Infection of Eye or Lid q q q Muscle Pain q q q
Stye or Chalazion q q q Joint Pain q q q
Flashes/Floaters in Vision q q q LYMPHATIC/HEMATOLOGIC
Tired Eyes q q q Anemia q q q
ENDOCRINE Bleeding Problems q q q
Thyroid/Other Glands q q q ALLERGIC/IMMUNOLOGIC q q q
PSYCHIATRIC q q q
If you answered YES to any of the above or have a condition not listed, please explain and list medications:
________________________________________________________________________________
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________________________________________________________________________________
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_________________________________________ ___________________________________
Doctor’s Signature Date