Daiber Vision Care Medical History Questionnaire

DAIBER VISION CARE MEDICAL HISTORY QUESTIONNAIRE

NAME ______DATE ______/______/______

ADDRESS ______HOME PHONE (______)______

CITY______ST______ZIP______CELL PHONE (______)______

BIRTH DATE ______/______/______SSN: ______/______/______WORK PHONE (______)______

MEDICAL DOCTOR/CLINIC: ______DR’S PHONE (______)______

LAST EYE EXAM_____/_____/_____ LAST MEDICAL EXAM____/_____/_____ PHARMACY USED ______

IF PATIENT IS A MINOR/CHILD, PLEASE LIST PARENT/GUARDIAN NAME______

EMPLOYER______SCHOOL (IF STUDENT)______

WHO IS IT OK TO DISCUSS YOUR PERSONAL HEALTHCARE INFORMATION WITH?

NAME______RELATIONSHIP______DOB______PHONE #______

NAME______RELATIONSHIP______DOB______PHONE #______

OCULAR HISTORY

HAVE YOU HAD ANY OF THE FOLLOWING?□ CROSSED EYES□ RETINAL DISEASE □ CATARACTS □ EYE INFECTIONS

□ LAZY EYE □ DROOPING EYELID □ FEVER BLISTERS□ SHINGLES □ GLAUCOMA

Explanation:______

PLEASE LIST ANY OCULAR (EYE)SURGERIES YOU HAVE HAD, INCLUDING DATES: ______

HAS ANYONE IN YOUR FAMILY (Parents, grandparents, siblings, or children) HAD ANY OF THE FOLLOWING?

CONDITION / NO / YES / RELATIONSHIP TO YOU (maternal/paternal grandparent, etc.)
BLINDNESS / □ / □
CATARACT / □ / □
CROSSED EYES / □ / □
GLAUCOMA / □ / □
MACULAR DEGENERATION / □ / □
RETINAL DETACHMENT/DISEASE / □ / □
ARTHRITIS / □ / □
CANCER
Type: / □ / □
DIABETES / □ / □
HEART DISEASE / □ / □
HIGH BLOOD PRESSURE / □ / □
KIDNEY DISEASE / □ / □
LUPUS / □ / □
THYROID DISEASE / □ / □
OTHER: / □ / □

ARE YOU PREGNANT AND/OR NURSING?□ NO□ YES

DO YOU WEAR GLASSES?□ NO□ YES IF YES, HOW OLD ARE THEY?______

DO YOU WEAR CONTACT LENSES?□ NO□ YES IF YES, WHAT KIND ARE THEY?______

TYPE: □ RIGID □ SOFT □ OVERNIGHT WEAR □ OTHER______Are they comfortable? □YES □ NO

ARE YOU INTERESTED IN CONTACTS TODAY? □ NO □ YES

MEDICAL HISTORY

LIST ALL MAJOR INJURIES, SURGERIES, AND/OR HOSPITALIZATIONS YOU HAVE HAD: ______

WHAT MEDICATIONS ARE YOU ALLERGIC TO? □ NO KNOWN DRUG ALLERGIES

______

WHAT MEDICATIONS DO YOU TAKE, INCLUDING OVER THE COUNTER, VITAMINS, AND EYE DROPS?

MEDICATION / DOSAGE AMOUNT / HOW OFTEN / REASON TAKING

SOCIAL HISTORY

DO YOU DRIVE? □ NO □ YES IF YES, DO YOU HAVE VISUAL DIFFICULTIES WHEN DRIVING? □ NO □ YES

DO YOU USE TOBACCO PRODUCTS?□ NO□ YES (IF YES, TYPE/AMT/HOW LONG______)

DO YOU DRINK ALCOHOL?□ NO□ YES (IF YES, TYPE/AMT/HOW LONG______)

DO YOU USE ILLEGAL DRUGS?□ NO□ YES (IF YES, TYPE/AMT/HOW LONG______)

HAVE YOU EVER BEEN EXPOSED TO OR INFECTED WITH: □ GONORRHEA □ HEPATITIS □ HIV □ SYPHILIS □ NONE OF THESE

REVIEW OF SYSTEMS Do you currently have (or have you ever had) any problems in the following areas?

NO / YES / NO / YES / NO / YES
EYES:
LOSS OF VISION / □ / □ / CONTITUTIONAL:
FEVER, WEIGHT LOSS/GAIN / □ / □ / GASTROINTESTINAL:
DIARRHEA / □ / □
BLURRED VISION / □ / □ / INTEGUMENTARY:
SKIN / □ / □ / CONSTIPATION / □ / □
DISTORTED VISION/HALOES / □ / □ / NEUROLOGICAL:
HEADACHES / □ / □ / GENITOURINARY:
GENITALS/KIDNEY/BLADDER / □ / □
LOSS OF SIDE VISION / □ / □ / MIGRAINES / □ / □ / BONES/JOINTS/MUSCLES:
RHEMATOID ARTHRITIS / □ / □
DOUBLE VISION / □ / □ / SEIZURES / □ / □ / MUSCLE PAIN / □ / □
DRYNESS / □ / □ / ENDOCRINE:
THYROID/OTHER GLANDS / □ / □ / JOINT PAIN / □ / □
MUCUS DISCHARGE / □ / □ / EAR, NOSE, MOUTH, THROAT:
ALLERGIES/HAY FEVER / □ / □ / LYMPHATIC/HEMATOLOGIC
ANEMIA / □ / □
REDNESS / □ / □ / SINUS CONGESTION / □ / □ / BLEEDING PROBLEMS / □ / □
SANDY OR GRITTY FEELING / □ / □ / RUNNY NOSE / □ / □ / ALLERGIC/IMMUNOLOGIC / □ / □
ITCHING / □ / □ / POST-NASAL DRIP / □ / □ / PSYCHIATRIC / □ / □
BURNING / □ / □ / CHRONIC COUGH / □ / □ / EXPLANATION OF ANY CONDITIONS ABOVE:
______
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FOREIGN BODY SENSATION / □ / □ / DRY THROAT/MOUTH / □ / □
EXCESS TEARING/WATERING / □ / □ / RESPIRATORY:
ASTHMA / □ / □
GLARE/LIGHT SENSITIVITY / □ / □ / CHRONIC BRONCHITIS / □ / □
EYE PAIN/SORENESS / □ / □ / EMPHYSEMA / □ / □
CHRONIC EYE/LID INFECTION / □ / □ / VASCULAR/CARDIOVASCULAR:
DIABETES / □ / □
STYES OR CHALAZION / □ / □ / HEART PAIN / □ / □
FLASHES OR FLOATERS IN VISION / □ / □ / HIGH BLOOD PRESSURE / □ / □
TIRED EYES / □ / □ / VASCULAR DISEASE / □ / □

Doctor’s Signature______Date______