THE RETINA GROUP - MEDICAL HISTORY QUESTIONAIRE
Patient Name:______DOB: ______Date: ______
Present Ocular Complaints Yes No Family Medical History
Yes No ___ Relationship
Distorted vision □ □ Arthritis □ □ ______
Sudden Loss of vision □ □ Cancer □ □ ______
Loss of side vision □ □ Diabetes □ □ ______
Double vision □ □ Heart Disease □ □ ______
Burning/ itching/tearing □ □ Hypertension □ □ ______
Glare or light sensitivity □ □ Kidney Disease □ □ ______
Eye pain/soreness/tenderness □ □ Lupus □ □ ______
Flashes/Floaters/Veil/Curtain □ □ Thyroid Disease □ □ ______
Other ______□ □ Tuberculosis □ □ ______
Family Ocular History______Yes No List of Eye Medications & Drops
Blindness □ □ ______
Glaucoma □ □ ______
Macular degeneration □ □ ______
Retinal detachment □ □ ______
Other ______□ □ ______
EYE Surgeries:
Procedure ______Date______Doctor who performed____
List all OTHER surgeries and hospitalizations with dates:
______
______
______
______
______
List all Medications or provide list:
______
______
______
______
______
______
Please list all medication ALLERGIC REACTIONS or sensitivities & reaction to the drug
______
______
______
______
General Medical History
(Circle specific diagnosis) Yes No Kidney Problems □ □
(Stones, kidney failure, blood in urine, dialysis)
Cancer □ □ MRSA □ □
Type/Part of Body/Date of diagnosis & treatment (Methicillin-Resistant Staphylococcus Aureus)
______Musculoskeletal Problems □ □
______(Arthritis, muscle aches, joints, osteoporosis)
Cardiovascular □ □ Neurological □ □
(Numbness, weakness, neuropathy, Multiple
(Heart attack, angina, congestive heart failure, Sclerosis, restless leg syndrome, Parkinson’s)
irregular beat, defibrillator, pacemaker, stroke,
stent) Pregnant (currently) □ □
Ears, Nose, Throat □ □ Psychiatric □ □
(Hearing difficulty, ringing, sore throat, sinusitis) Depression, anxiety, bipolar)
Endocrine/ Diabetes □ □ Respiratory Problems □ □
How Long ______(Asthma, emphysema, oxygen use, shortness of
Insulin dependant / how long? ______breath, cough, wheezing, sleep apnea)
Last Blood Sugar ______last A1C______
Tuberculosis, treatment date ______□ □
Gastrointestinal □ □ Sexually Transmitted Diseases □ □
(Heartburn, nausea, vomiting, diarrhea, stomach ulcer Dates of Treatment: from ______to ______
Crohn’s disease, colon cancer)
Hepatitis A, B, or C □ □ Skin Problems □ □
HIV (AIDS) □ □ Psoriasis, eczema, basal cell, vitiligo)
High Blood Pressure: □ □ Thyroid Problems □ □
How Long ______goiter, overactive, underactive)
Last Blood Pressure ______
Is it Controlled ______Other ______
______
Social History
Current Occupation: ______Yes No
Do you drink alcohol? ______Do you smoke cigarettes/cigars □ □
If yes, Frequency:______Quantity: ______If yes, how much per day: ______
How many years: ______
Verified, reviewed and completed with the patient: Technician: Date:
Physician Signature:______Date:______
Physician Notes: