MEDICAL HISTORY QUESTIONNAIRE
NAME:_______________________________________________________________________
REVIEW OF SYSTEMS
Primary reason for today’s (first) visit:_______________________________________________
Do you presently have any or currently experiencing any problems in the following areas?
If “YES”, give an explanation.
YES NO
Constitutional
Chronic fever, unexplained weight loss
Eyes
Blurred vision
Distortion of vision
(example: straight lines look wavy)
Loss of central or side vision
Floaters / Cobwebs
Flashes of Light
Eye pain
Light Sensitivity
Double Vision
Decreased Vision
Itching, burning
Discharge, redness
Gritty felling, dryness
Tearing
Feels like something in eye
Ears, Nose, Mouth, Throat
Hearing loss, sinus problems
Cardiovascular
Chest pain, irregular heart beat
Respiratory
Shortness of breath, wheezing
Gastrointestinal
Abdominal pain, nausea
EXPLANATION OF PROBLEM
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EXPLANATION OF PROBLEM
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REVIEW OF SYSTEMS (cont’d)
Genitourinary
Blood in urine, discomfort on urination
Musculoskeletal
Joint pain
Integumentary
YES NO
EXPLANATION OF PROBLEM
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Skin rashes, itching, pigmented lesion
Neurological
Numbness, muscular weakness, headache
Psychiatric
Feeling of sadness, anxiety
Endocrine
Excessive thirst, excessive urination
Cold intolerance
Hematologic/lymphatic
Easy bleeding, easy bruising
Swollen glands
Allergic/immunologic
Seasonal allergies, hives
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1. Do you have any medication allergies? [ ] NO [ ] YES (please list)
______________________________________________________________________________
______________________________________________________________________________
2.
List any medications (other than eyedrops) that you are currently using:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3.
Were you born premature?
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PAST EYE HISTORY
YES NO
1.
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WHICH EYE?
Have you ever had an eye injury:
[ ] [ ] Right____Left____ Both_______
Have you ever cataract surgery:
[ ] [ ] Right____Left____ Both_______
Do you have Glaucoma:
[ ] [ ] Right____Left____ Both_______
Are you on eye drops for Glaucoma:
[ ] [ ] Right____Left____ Both_______
Have you had surgery of Glaucoma:
[ ] [ ] Right____Left____ Both_______
Do you have a history of Retinal disease:
[ ] [ ] Right____Left____ Both_______
Do you have a history of Macular Degeneration:
[ ] [ ] Right____Left____ Both_______
Do you have a history of Diabetic Retinopathy:
[ ] [ ] Right____Left____ Both_______
Have you been treated for Retinal Disease:
[ ] [ ] Right____Left____ Both_______
If yes, please answer the following questions:
Injection of medication:
[ ] [ ] Right____Left____ Both_______
Laser treatment:
[ ] [ ] Right____Left____ Both_______
Surgery treatment (hospital setting):
[ ] [ ] Right____Left____ Both_______
Name of surgery (if known):
____________________________________
10. Eye drops currently in use: (list)
[ ] [ ]
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
PAST MEDICAL / SURGICAL HISTORY
1.
Are you being treated for any medical conditions?
YES NO
Diabetes:
Do you use Insulin:
Stroke:
High Blood Pressure:
Rheumatoid Arthritis:
2.
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Heart Disease (irregular heart
beat, heart attack, bypass surgery)
Renal Disease :
Are you on Dialysis:
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List any major surgical procedures (except eye):
______________________________________________________________________________
______________________________________________________________________________
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FAMILY HISTORY
YES NO
EXPLANATION / RELATIONSHIP
OCULAR
Blindness
Night Blindness
Cataract
Glaucoma
Macular degeneration
Retinal detachment
Other (list)
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MEDICAL
Diabetes
High Blood Pressure
Heart Disease
Rheumatoid Arthritis
Other (list)
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SOCIAL HISTORY
GENERAL
Do you drink alcohol?
Do you smoke?
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How much per day?___________Years?________
How many packs per day?_______Years?_______
Additional Comments:__________________________________________________________
______________________________________________________________________________
Patient Name:__________________________________________________________________
Patient Signature:_____________________________________________Date:_____________