Medical History Questionnaire

Medical History Questionnaire

Today's Date*
Patient Name*
Patient Birth Date
Social Security #
Phone*
Secondary Phone
Address
City
Zip Code
Email Address
Name of Medical Doctor
Doctor's Phone Number
Guardian (If Applicable)

Medical History

Do you have any allergies to medications?
If yes, please explain:
List any medication/s you take (including oral contraceptives, aspirin, & over-the-counter medications)
List all major injuries, surgeries, and/or hospitalizations you have had
Choose any of the following that you have had
Are you pregnant or nursing?
Do you wear glasses?
If yes, how old is your present pair?
Do you wear contacts?
If yes, how old is your present pair?
Type of contact lenses
Are they comfortable?

Family History

Blindness
Relationship to you
Cataracts
Relationship to you
Crossed Eyes
Relationship to you
Glaucoma
Relationship to you
Macular Degeneration
Relationship to you
Retinal Disease
Relationship to you
Diabetes
Relationship to you
Arthritis
Relationship to you
Cancer
Relationship to you
Heart Disease
Relationship to you
High Blood Pressure
Relationship to you
Kidney Disease
Relationship to you
Lupus
Relationship to you
Thyroid Disease
Relationship to you
Other
Relationship to you

Social History

Do you drive?
If yes, do you have visual difficultly when driving?
If yes, please describe
Do you use tobacco products?
If yes, type/amount
Do you drink alcohol?
If yes, type/amount
Do you use illegal drugs?
If yes, what type
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:

System Constitutional
Fever, Weight Loss/Gain
Integumentary (Skin)
Neurological
Headaches
Migraines
Seizures
Eyes
Blurred Vision
Distorted Vision/Halos
Loss of Side Vision
Double Vision
Dryness
Discharge
Redness
Sandy or Gritting Feeling
Itching
Burning
Foreign Body Sensation
Tearing/Watering
Glare/Light Sensitivity
Eye Pain or Soreness
Tired Eyes
Sties
Ears, Nose Mouth, Throat
Allergies
Sinus Congestion
Post Nasal Drip
Chronic Cough
Dry Mouth
Throat
Respiratory
Asthma
Chronic Bronchitis
Emphysema
Vascular/Cardiovascular
Diabetes
Heart
High Blood Pressure
Gastrointestinal
Constipation
Acid Reflux
Bones/Joints/Muscles
Arthritis
Muscle/Joint Pain
Lymphatic/Hematologic
Anemia
Bleeding Problems
Psychiatric
If you answered YES to any of the above or has a condition not listed, please explain
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