MEDICAL HISTORY QUESTIONNAIRE
Name: ______________________________________ Date of Birth: ____/____/______
Today’s Date: _____/______/_______
Primary Care Physician:
_________________________________
Referring Dr._______________________________________
Local Pharmacy:__________________________
Location(street
& city) ______________________________Phone #__________________
Mail Order Pharmacy: _________________________________________
Race: □ American Indian or Alaska Native □ Asian □
Black or African American
□ Native Hawaiian or Other Pacific Islander □ White or Caucasian □ Other _____________
□ Unknown
Ethnicity: □ Hispanic
□ Not Hispanic
Preferred Language: □ English □ French
□ Italian □ Japanese □ Portuguese □ Russian □ Spanish
Allergies:
Reaction: Severity:
__________________________ _______________________________ mild / moderate / severe
__________________________ _______________________________ mild / moderate / severe
__________________________
_______________________________ mild / moderate / severe
Past Ocular Health(please check all that apply):
□ Overall Healthy □ Diabetic Retinopathy
□ Iritis □ Optic Neuritis □ Amblyopia (Lazy eye)
□ Dry Eye □ Retinal Detachment/Tear □ Cataracts
□Glaucoma □ Wet Macular Degeneration □ Dry Macular Degeneration □Retinal disease
□Conjunctivitis □ Injury/Trauma □ Uveitis
Other_______________________________________________________________
Ocular Surgeries:(Please mark all that apply)
□ No prior ocular surgery □ Foreign Body Removal □ Punctal Plugs
□ Yag Capsulotomy □ Blepharoplasty □ Glaucoma Surgery
□ Vitrectomy □ Laser surgery for glaucoma □ Radial Keratotomy
□Cataract Implant □ PRK/LASIK (refractive surgery)
□ Strabismus surgery (eye muscle surgery)
Other_______________________________________________________________
Current
Eye Medications: (Please list)
______________________________________________________________________________________
Systemic Illnesses that currently have or have had in the past:
□ Acid Reflux □ Carotid Artery disease □ Heart Attack
□ Lupus
□ Ankylosing Spondylitis □ Congestive Heart Failure □ Heart Disease
□ Migraine
□ Anxiety Disorders □ COPD
□ Hepatitis
□ Multiple Sclerosis
□ Arrhythmia □ Deep Vein Thrombosis
□ High Blood Pressure □ Rheumatoid Arthritis
□ Arthritis
□ Depression □ High Cholesterol
□ Seasonal allergies
□ Asthma □
Diabetes □ HIV/AIDS
□ Stroke/TIA
□ Auto Immune Disease □ Gastric ulcers □ Kidney Disease
□ Thyroid Disease
□ Cancer
Active Infections for which you are being treated: _______________________________________________________
Other__________________________________________________________________________________________
Major Surgeries: (Please list)
______________________________________________________________________________________
______________________________________________________________________________________
Current Medications: (Please list, or reference a list you provide
to us)
______________________________________________________________________________________
______________________________________________________________________________________
Patient Name: _________________________________________
Date of Birth: _____________________________
Family History (members of your family
other than yourself):
□ Diabetes □ Stroke
□ Blindness □ Macular Degeneration □ Arthritis
□ Cancer
□ TB □ Cataracts
□ Retinal Disease □ Lazy Eye
□ Heart Disease
□ Kidney Disease □ Glaucoma
□ High Blood Pressure
Other_______________________________________________________________
Social History: (Please mark all that apply)
Smoking:
□ current every day smoker □ current some day smoker □ former smoker
□ never smoked
Circle applicable: cigarettes/pipe/cigar □ 1 pack/day □1/2 pack/day
explain other quantities: ________________________
Alcohol Use: □ Yes □ No If yes, how much
and how often?_______________________________________________
Review of Systems:
| Eyes
□ Previous Surgery □ Contact Lens □ Pain
□ Double Vision □ Glaucoma □ Cataracts
□ Macular Degeneration □ Dry Eyes □ Flashes
□ Floaters Ear, Nose, and Throat □ Hard of Hearing
□ Ringing in Ears □ Vertigo Cardiovascular □ Chest Pain
□ Dizziness □ Fainting Spells □ Shortness of Breath
□ Irregular Heart Beat □ Difficulty Lying Flat Constitutional □ Fatigue / Weakness
□ Fever □ Weight Gain / Loss
| Respiratory □ Cough □ Congestion
□ Wheezing □ Asthma Gastrointestinal □ Heartburn
□ Nausea / Vomiting □ Jaundice / Hepatitus Genito-Urinary □ Pain / Difficulty
□ Blood in Urine □ History of Kidney Stones
□ History of STD’s Psychiatric □ Anxiety / Depression □ Mood Swings
□ Difficulty Sleeping Endocrine □ Increased Thirst
□ Increased Hunger □ Increased Urination □ Increased Sweating
□ Fingernail Changes | Blood / Lymphnodes □ Easy Bruising
□ Gums Bleed Easy □ Prolonged Bleeding □ Heavy Aspirin Use MusculoSkeletal □ Stiffness
□ Arthritis □ Joint Pain / Swelling Skin □ Rash / Sores
□ Lesions □ Hives / Eczema Neurological □ Seizures
□ Weakness / Paralysis □ Numbness □ Tremors Immunologic
□ Hives □ Itching □ Runny Nose □ Sinus
Pressure |