Medical History Questionnaire
Name:______Today’s Date______
Date of Birth______Reason for todays visit:______
Eye History: (please circle all that apply)
Vision LossBlurred VisionLoss of Side Vision Double Vision
FloatersFlashesDistortionForeign Body Sensation
RednessPain/Soreness Eye InjuryGlare/Light Sensitivity
Other:______
List all previous eye surgeries, lasers, or injuries: ______
______
Do you currently have any problems in the following areas? Please circle all that apply:
General/Constitutional:
fever, weight loss, unusually tired, etc.
Ear, Nose, Throat:
runny nose, chronic cough, dry throat/mouth, etc.
Cardiovascular:
high blood pressure, irregular heart beat, coronary artery disease, chest pain, shortness of breath, etc.
Respiratory:
wheezing, shortness of breath, asthma, chronic cough, bleeding, etc.
Gastrointestinal:
Nausea, vomiting, acid reflux, ulcers, irregular bowel movements, bleeding, jaundice, etc.
Genitals/Kidney/Bladder:
painful urination, frequent urination, bleeding, etc.
Muscles/Bones/Joints:
joint pain, stiffness, swelling, cramps, arthritis, etc.
Skin:
growths, rash, cancer, etc.
Neurological:
numbness, weakness, headache, seizures, stroke, etc.
Psychiatric:
anxiety, depression, psychosis, insomnia, etc.
Endocrine:
diabetes, hypothyroid, hyperthyroid, etc.
Blood/Lymph:
high cholesterol, anemia, bleeding problems, etc.
Allergic/Immunologic:
sneezing, itching, hives, lupus, psoriasis, etc.
Other:______
______
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List any medications you currently take and dosage: ______
______
Do you have any allergies to any medications?YESNO
If YES, list the medications:______
List all major illnesses/injuries (diabetes, high blood pressure, heart attack, cancer, eye trauma, etc.)
______
______
List any surgeries you have had:______
______
Family History: (Mother, Father, Grandparent, Sibling)
Has any member of your family had these diseases?
Blindness, Glaucoma, Retinal Detachment, Macular Degeneration
Diabetes, High Blood Pressure, Heart Disease, Stroke, Cancer
other heritable disease:______
Social History:
Current Occupation:______
Does your vision limit any activities of daily living (driving, reading, work, sports, etc) YESNO
Have you ever had a blood transfusion?YESNO
Do you drink alcohol?YESNOIf YES, how much______
Do you smoke?YESNOIf YES, how much______years?______
List doctors you are currently seeing:______
______
Patient Signature:______Date:______
For Office Use Only:
Physician Signature:Date: