Medical History Questionnaire

Date
MM slash DD slash YYYY
Patient Name
First Last
Date of Birth
MM slash DD slash YYYY
Date of Last Eye Exam
MM slash DD slash YYYY
Personal Medical Information:
Do you have problems with any of these systems? If Yes, please check box.
- Allergic/Immunologic
- Genitourinary
- Nervous System Mental
- Blood/Lymph/Cancer
- Headaches/Migraines
- Respiratory
- Cardiovascular
- High blood pressure
- Skin
- Diabetes
- High Cholesterol
- Ear/Nose/Throat
- Musculoskeletal/Arthritis
- Endocrine (Glands)
- Gastrointestinal
- Surgeries
If you have had surgeries, what type & when?
Are you in good health?
- Yes
- No
Do you take medications?
- Yes
- No
Please list names and how often:
Name How often
Any allergic reactions to medications or other substances?
- Yes
- No
If yes, please list:
Name of general physician
Phone
Do you have any of the following?
If Yes, please check box.
- Blurred Vision
- Eye Surgeries
- Wear Contacts
- Cataracts
- Glaucoma
- Wear Glasses
- Dry Eyes
- Macular Degen.
- Eye Injuries
- Retinal Detachment
Any other eye problems at this time?
Please explain
Please check Yes or No
Do you smoke?
- Yes
- No
How much?
Do you drink alcohol?
- Yes
- No
How much?
Do you use other substances?
- Yes
- No
Do you have family history of any of the following?
If Yes, please check box.
- Cataracts
- High blood pressure
- Retinal Detachment
- Diabetes
- High Cholesterol
- Glaucoma
- Macular Degen.
Please explain any boxes you have checked
Please sign below that you have reviewed all information above and it is correct to the best of your knowledge.
Signature
Date
MM slash DD slash YYYY
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