MEDICAL HISTORY QUESTIONNAIRE Today S Date

MEDICAL HISTORY QUESTIONNAIRE Today’s Date://

Name: Last Eye Exam:, 20

Name of Medical Doctor: Last Medical Exam:, 20

Doctor’s Phone: ()-- Employer/Occupation:

School: Height: Weight:lbs

ARE YOU INTERESTED IN…?(Circle any you have interest in)

(Contact lenses that are clean and fresh every day?) (A non-surgical alternative to glasses or contacts?)

(Contact lenses you could safely sleep in overnight?) (Laser Vision Correction?)

GLASSES AND CONTACT LENS STATUS

Yes No Do you have glasses? How old are they? How Many Pairs?

YesNo Do you have sun-sensitive lenses in your glasses or use clip-ons over your lenses?

YesNo Do you have Contact Lenses? What Type?

What solution do you use?

EYE AND VISION CONDITIONS

Problems with/when…(Circle all that apply)

(eye irritation when it is windy) (reading) (working on a computer)

(watching TV) (night driving) (playing golf or other sports) (eye fatigue)

(This topic will be discussed more in the exam room and involves issues like blurred vision, redness/soreness)

SOCIAL HISTORY(this information is kept strictly confidential. However, you may discuss this with your doctor.)

I smoke... (None) (<1 pack/day) (1-2 packs/day) (> 2 packs/day) Former smoker (Quit)

I drink… (None) (Only socially) (1-2 drinks daily) (>2 drinks daily)

Do you use illegal drugs? (No) (Yes) If yes, type/amount/how long?

GENERAL MEDICAL HISTORY AND CONDITIONS(Circle all that apply)

(High Cholesterol) (Diabetes) (High Blood Pressure) (Fever, Weight Loss/Gain)

(This topic will be further discussed in the exam room as well as current medications and allergies)

The Following is for Technician use only

Did you bring your glasses and any prescription sunglasses with you for your exam today?

(Yes)(No)(I don’t have prescription sunglasses)

Do you spend a considerable amount of time outdoors? Like a couple hours or more a day?

(Yes)(No)

If yes doing what?

(Fishing)(Golfing)(Hiking)(Biking)(Mowing)

(Sports)(Gardening)(Boating)(Running)(Camping)

(Other)(A variation of many things)

Do you reading a lot or spend a lot of time in front of a computer screen? More than 2 hours a day?

(Yes)(No)

If yes what is the thing being looked at?

(Book/Magazine/Newspaper)(TV)(Ipad/Ipod)

(Computer)(Phone)(Other)

(Nothing)(Non-Prescription Sunglasses)

(Prescription Sunglasses)(Other)