Medical History Questionnaire
Name:______Date of Birth:______Ethnicity:______
Primary Care Physician:______Referring Doctor:______
Referring Optometrist:______
PLEASE MARK ALL THAT APPLY. THINGS THAT YOU ARE TREATED FOR, OR HAVE A HISTORY OF:
Past Ocular History:
o Overall Healthy
o Amyblopia
o Astigmatism
o Cataracts
o Diabetic Retinopathy
o Dry Eyes
o Glasses/Contact lenses
o Glaucoma
o Iritis
o Keratoconus
o Macular Degeneration
o Optic Neuritis
o Retinal Detachment/ Tear
o Other:______
Ocular Surgeries:
o No prior ocular surgery
o Blepharoplasty
o Cataract Surgery
o Corneal transplant
o Retinal Laser Surgery
o LASIK
o Punctal plugs
o Strabismus (eye muscle) surgery
o Trabeculectomy (Glaucoma surgery)
o Vitrectomy
o Other:______
Ocular Significant Illnesses/ Systemic Illnesses:
o Overall Healthy
o Diabetes
o Hypertension
o Graves Disease
o Hyperthyroid
o Hypothyroid
o Rheumatoid Arthritis
o Sjogren's Syndrome
o Lupus
o Lyme Disease
o Multiple Sclerosis
o Herpes
o HIV positive
o AIDS
o Other:______
Infections- Past and Present
o Overall Healthy
o Chicken Pox
o Hepatitis A/ B/ C
o Herpes Simplex
o Herpes Zoster/ Shingles
o HIV/AIDS
o Meningitis
o MRSA
o Syphilis
o Toxoplasmosis
o Tuberculosis
o Wound Infection
o Other:______
Head/ Ocular Trauma:
o Assault
o Blunt trauma
o Chemical injury
o Eye injury
o Foreign body
o Job/ sports Injury
o Motor Vehicle Accident
o Sharp Trauma
o Other:______
Other Surgeries: (Please list)______
Family History:
o Blindness
o Cancer
o Cataracts
o Diabetes
o Glaucoma
o Heart Disease
o High Blood Pressure
o Kidney Disease
o Lazy Eye
o Macular Degeneration
o Migraine
o Retinal detachment
o Stroke
o Thyroid Disease
o Other:______
Social History:
o Alcohol Use
o Current smoker
o Former smoker
o Never smoked
o Occupation: ______
o Pregnant/ Nursing- Delivery Date:______
ALL Medications Including Eye Drops/ Vitamins: ______
______
Medication Allergies: ______
Have you had a Strep Pneumonia Vaccine in the past 10 years? ____Yes ____No
Have you had a flu shot for the current year? _____Yes _____No
Review of Systems: (Please mark all that apply):
Constitutional
o Fever
o Weight loss
o Loss of appetite
Skin
o Skin Cancer
o Eczema
o Psoriasis
o Roasacea
o Other:______
Ears, Nose, Mouth, Throat
o Hearing Loss
o Ear Pain
o Dizziness
o Sinus Congestion
o Dry Throat/ Mouth
o Other:______
Respiratory
o Asthma
o Bronchitis
o Emphysema
o COPD
o Lung Cancer
o Tuberculosis
o Other:______
Cardiovascular
o High blood pressure
o High Cholesterol
o Atherosclerosis
o Heart Disease
o Atrial Fibrillation
o Pacemaker
o Heart Attack (MI)
o Other:______
Gastrointestinal
o Colon Cancer
o Liver Cancer
o Diarrhea
o Constipation
o Ulcers
o Reflux/Heartburn
o Crohn's Disease
o Other:______
Genitourinary
o Kidney Disease
o Bladder Infection
o Prostate Cancer
o Ovarian/ Uterine cancer
o BPH
o Other:______
Musculoskeletal
o Rheumatoid Arthritis
o Arthritis
o Fibro/Polymyalgia
o Sarcoidosis
o Osteoporosis
o Gout
o Other:______
Neurological
o Bell's Palsy
o Dementia
o Brain Tumor
o Parkinson's Disease
o Migraines
o Multiple Sclerosis
o Migraines
o Seizures
o Stroke
o Headaches
o Dizziness
o Other:______
Endocrine
o Type I Diabetes (Juvenile)
o Type II Diabetes
o Diabetic Suspect
o Thyroid Disorder
o Graves Disease
o Pituitary Tumor
o Other:______
Hematologic/ Lymphatic
o AIDS/HIV
o Anemia
o Bleeding disorder
o Breast Cancer
o Hepatitis
o Leukemia
o Lupus
o Lymphatic Cancer
o Other:______
Psychiatric
o Anxiety
o Depression
o Bipolar Disorder
o PTSD
o Schizophrenia
o Other:______
What brings you in to see us today?______
Physician Signature______