Medical History Questionnair

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

 

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