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:NameHow often Any allergic reactions to medications or other substances? Yes No If yes, please list: Name of general physician PhoneDo 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 NoDo 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. SignatureDate MM slash DD slash YYYY CAPTCHA