Medical History Questionnaire
Name: ______Today’s Date: ______
What is the main reason for today’s exam? ______Approximately when was your last eye exam? ______Any allergies to medications? Yes No
If allergic to medications, explain:______
List any medications you take (including aspirin, over-the-counter medications & home remedies), and state reason for taking medication:
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1) ______Reason ______
2) ______Reason ______
3) ______Reason ______
4) ______Reason ______
5) ______Reason ______
6) ______Reason ______
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Primary Care doctor: ______Phone: ______
Ophthalmologist or referring doctor (if any): ______Phone: ______
List major injuries and prior surgeries you have had: ______
Are you pregnant and/or nursing? Yes No
Do you wear glasses (check all that apply):
None Reading Distance Safety Sports Computer
Bifocals Trifocals Progressives (no-line bifocals)
Do you wear contact lenses?
None Rigid Soft Lenses/Disposables Extended Wear
Contacts Type/Brand: ______Are they comfortable? Yes No
If using disposable lenses, how often do you discard them? (ex: dispose every 2 weeks): ______
What duration of time are contacts worn? (ex: Mon-Fri from 6:30am-7:00pm): ______
SOCIAL HISTORY
Hobbies / Interests: ______
Do you drive? Yes No
If yes, do you have visual difficulty when driving? (please specify): ______
Do you use tobacco products? Yes No If yes, type/amt/how long: ______
Do you drink +2 alcoholic beverages/day? Yes No If yes, type/amt/how long: ______
Do you use illegal drugs? Yes No If yes, type/amt/how long: ______
GENERAL HEALTH CONDITION
Do you have or ever had any problems in the following areas?
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AIDS/HIV Yes No
Allergies/Hay Fever Yes No
Heart disease Yes No
High blood pressure Yes No
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Continued on back…
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Asthma Yes No
Thyroid Condition Yes No
Cancer Yes No
Headaches Yes No
Migraines Yes No
High Cholesterol Yes No
Stroke Yes No
Diabetes Yes No
Arthritis Yes No
Lupus Yes No
Seizures Yes No
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If yes, please state type of cancer: ______
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EYE HISTORY
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Amblyopia (lazy eye) Yes No
Strabismus (eye turn) Yes No
Loss of Vision Yes No
Blurred Vision Distance Yes No
Blurred Vision Near Yes No
Loss of Side Vision Yes No
Blindness Yes No
Color Blindness Yes No
Double Vision Yes No
Dryness Yes No
Mucous Discharge Yes No
Redness Yes No
Sandy or Gritty Feeling Yes No
Itching Yes No
Burning Yes No
Excess Tearing/Watering Yes No
Glare/Light Sensitivity Yes No
Eye Pain or Soreness Yes No
Tired Eyes Yes No
Sties or Chalazion Yes No
Flashes/Floater in Vision Yes No
Lasik Yes No
Cataracts/ Surgery Yes No
Retinal Detachment/Holes Yes No
Macular Degeneration Yes No
Glaucoma Yes No
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FAMILY HISTORY
To the best of your knowledge, please note any family history (parents, grandparents, siblings, children) for the following conditions:
Condition Relationship to You
Amblyopia (lazy eye) Yes No ______
Blindness Yes No ______
Color Blindness Yes No ______
Glaucoma Yes No ______
Macular Degeneration Yes No ______
Strabismus (eye turn) Yes No ______
Retinal Detachment Yes No ______
Diabetes Yes No ______
High Blood Pressure Yes No ______
High Cholesterol Yes No ______
Lupus Yes No ______
Thyroid Disease Yes No ______
Cancer Yes No ______
If yes, please state type of cancer: ______
Thank you for your confidence
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