Medical History Questionnaire

Medical History Questionnaire

Medical History Questionnaire

Medical History Questionnaire

Medical History

Do you have any allergies to medications?

Do you have any allergies to medications?

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:

Are you pregnant and/or nursing?

Do you wear glasses?

If yes, how old is your present pair of lenses?

Do you wear contacts?

If yes, how old is your present pair of lenses?

Type of contact lenses

Other:

Are they comfortable?

Family History

Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:

Blindness

Cataracts

Crossed Eyes

Glaucoma

Macular Degeneration

Retinal Detachment/Disease

Arthritis

Cancer

Diabetes

Heart Disease

High Blood Pressure

Kidney Disease

Lupus

Thyroid Disease

Social History

This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.

Do you drive?

If yes, do you have visual difficulty when driving?

If yes, please describe

Do you use tobacco products?

If yes, type/amount/frequency

Do you drink alcohol?

If yes, type/amount/frequency

Do you use illegal drugs

If yes, type/amount/frequency

Have you ever been exposed to or infected with:

Review of Systems

Do you currently, or have you ever had any problems, in the following areas:

CONSTITUTIONAL

Fever, Weight Loss/Gain

INTEFUMENTARY (Skin)

NEUROLOGICAL

Headaches

Migraines

Seizures

EYES

Loss of Vision

Blurred Vision

Distorted Vision/Halos

Loss of Side Vision

Double Vision

Eye Pain/Soreness

Burning

Redness

Sandy/Gritty Feeling

GASTROINTESTINAL

Itching

Excess Tearing/Watering

Dryness

Foreign Body Sensation

Mucous Discharge

Chronic Infection of Eye/Lid

Sties or Chalazion

Glare/Light Sensitivity

Flashes/Floaters in Vision

Tired Eye

ENDOCRINE

Thyroid/Other Glands

EARS, NOSE, MOUTH, THROAT

Allergies/Hay Fever

Sinus Congestion

Runny Nose

Post-Nasal Drip

Chronic Cough

Dry Throat/Mouth

RESPIRATORY

Asthma

Chronic Bronchitis

Emphysema

VASCULAR/CARDIOVASCULAR

Diabetes

Heart Pain

High Blood Pressure

Vascular Disease

Diarrhea

Constipation

GENITOURINARY

Genitals/Kidney/Bladder

BONES/JOINTS/MUSCLES

Rheumatoid Arthritis

Muscle Pain

Joint Pain

LYMPATHIC/HEMATOLOGIC

Anemia

Bleeding Problems

PSYCHIATRIC

If you answered YES to any of the above or have a condition not listed, please explain and list medications:

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