MEDICAL HISTORY QUESTIONAIRE
NAME:__________________
BIRTHDATE:________________________
REFERRING PHYSICIAN (IF ANY):__________________________________
CURRENT EYE PROBLEM:_______________________________________
IF YOU DO NOT WANT APPOINTMENT REMINDERS LEFT ON YOUR ANSWERING MACHINE OR WITH ANOTHER PERSON
WHO MAY ANSER YOUR PHONE, PLEASE INITIAL HERE:_________________________
ALLERGIES:
MEDICATION
REACTION
SYSTEMIC MEDICATIONS: (YOU MAY ATTACH A LIST IF NEEDED OR CONTINUE ON THE BACK)
MEDICATION
STRENGTH
FREQUENCY
OPHTHALMIC MEDICATIONS (EYE DROPS):
MEDICATION
STRENGHTH
FREQUENCY
EYE (LEFT/RIGHT/BOTH)
SOCIAL HISTORY:
HEIGHT:___________ WEIGHT:____________
DO YOU SMOKE?________________
ARE YOU A FORMER SMOKER?___________
HOW MUCH?_________/ DAY / WEEK / MONTH
WHEN DID YOU STOP?________________
DO YOU DRINK ALCOHOL?
SOCIALLY
DO YOU DRIVE A CAR?
NEVER
YES NO
DO YOU LIVE ALONE? YES NO
EVERY DAY
FORMER DRINKER
MEDICAL HISTORY QUESTIONAIRE
GENERAL
EYES
CARDIOVASCULAR
REVIEW OF SYSTEMS
FEVER
WEIGHT LOSS (EXTREME)
WEIGHT GAIN (EXTREME)
FATIGUE (UNUSUAL)
OTHER:
PAIN
BLURRY VISION
VISION LOSS
ITCHING
MATTERING
FOREIGN BODY
GRITTY SENSATION
DRY EYE
TEARING
REDNESS
GLARE/HALOS
FLOATERS
FLASHING LIGHTS
DOUBLE VISION
OTHER:
CHEST PAIN
MURMURS
IRREGULAR HEART BEAT
HEART DISEASE
NEW PROBLEM:
OTHER:
RESPIRATORY
COUGH
HOASENESS
SHORTNESS OF BREATH
NEW PROBLEM:
OTHER:
ENT
HEARING LOSS
DRY MOUTH
CONGESTION
SORE THROAT
POST NASAL DRIP
DIZZINESS
TINNITUS (RINGING)
BLEEDING IN EARS
SINUSITIS
OTHER
PAST MEDICAL HISTORY
CHRONIC FATIGUE
HYPERCHOLESTEROLEMIA
CATARACTS
GLAUCOMA
RETINAL DETACHMENT
LAZY EYE (AMBLYOPIA)
DIABETIC RETINOPATHY
MACULAR DEGENERATION
STRABISMUS
PSEUDOTUMOR CEREBRI
IRITIS/UVEITIS
FLOATERS
FOREIGN BODY
OTHER:
HIGH BLOOD PRESSURE
MITRAL VALVE PROLAPS
ATRIAL FIBRILLATION
CONGESTIVE HEART FAILURE
HEART ATTACK
HEART DISEASE
IRREGULAR HEART BEAT
OTHER:
ASTHMA
BRONCHITIS
EMPHASEMA
HAY FEVER/ALLERGIES
TB (TUBERCULOSIS)
OTHER:
CANCER
MENIERES DISEASE
SINUSITIS
HEARING LOSS
OTHER:
MEDICAL HISTORY QUESTIONAIRE
ENDOCRINE
MUSCULOSKELETAL
GENITOURINARY
GI
SKIN
NEUROLOGICAL
PSYCHIATRIC
HEMATOLOGIC
ALL/IMMUNOLOGIC
FREQUENT URINATION
EXCESS HUNGER
EXCESS THIRST
HEAT INTOLERANCE
COLD INTOLERANCE
OTHER
STIFFNESS
MUSCLE PAIN
JOINT PAIN
ARTHRITIS
FIBROMYALGIA
OTHER:
EVER TAKEN FLOWMAX
VIAGRA/CIALIS/LEVITRA
FREQUENT URINATION
BLOOD IN URINE
PAIN ON URINATION
OTHER:
VOMITTING
DIARRHEA
HEARTBURN
NAUSEA
DIFFICULTY SWALLOWING
CONSTIPATION
OTHER
ITCHING
SCALING
RASH
BRUISING
HAIR LOSS
OTHER:
SEIZURES
PARALYSYS
GAIT PROBLEMS
PARASTHESIAS
INCOORDINATION
HEADACHES
ANXIETY
DEPRESSION
MENTAL DISORDER
ANEMIA
BLEEDING TENDENCY
BLOOD DISORDER
LYMPH NODE SWELLING
SEASONAL ALLERGIES
FREQUENT ILLNESSES
FOOD ALLERGIES
OTHER:
DIABETES TYPE 1
DIABETES TYPE 2
THYROID ABNORMALITIES
OTHER:
RHEUMATOID ARTHRITIS
OSTEOARTHRITIS
UNKOWN ARTHRITIS
FIBROMYALGIA
OTHER:
KIDNEY STONES
PROSTATE PROBLEMS:
MENAPAUSE
HYSTERECTOMY
PREGNANT
OTHER:
ULCERS
COLITIS
DIVERTICULITIS
CROHNS DISEASE
OTHER
PSORIASIS
SKIN CANCER
ROSACEA
OTHER:
STROKE
MYASTHENIA GRAVIS
PITUITARY TUMOR
BRAIN TUMOR
MIGRAINES
OTHER:
ANXIETY
DEPRESSION
OTHER:
CANCER:
ANEMIA
OTHER
HIV
SEASONAL ALLERGIES
SYSTEMIC LUPUS ERYTHEMATOSUS
OTHER:
MEDICAL HISTORY QUESTIONAIRE
ARE YOU CURRENTLY BEING TREATED FOR ANY ONGOING EYE PROBLEMS, OR HAVE YOU BEEN TREATED FOR ANY
CHRONIC EYE PROBLEMS IN THE PAST?
EYE (RIGHT/LEFT/BOTH
DIEASE
ARMD
GLAUCOMA
DIABETIC EYE DISEASE
MACULAR HOLE/PUCKER
DRY EYE
CATARACT
ALLERGIES
BLEPHARITIS/LID DISEASE
OTHER:
ONSET-IF KNOWN
FAMILY HISTORY-- IS THERE A FAMILY HISTORY OF:
RELATION

(MOTHER/FATHER, ETC)
EYE DISEASE
RELATION
(MOTHER/FATHER, ETC)
GLACOMA
DIABETES
ARMD
CATARACTS
STRABISMUS
STROKE
OTHER:
SYSTEMIC DISEASE
ALZHEIMER'S
ARTHRITIS
ASTHMA
CANCER
DIABETES
EMPHYSEMA
HEART DISEASE
HYPERTENSION
OTHER:
PAST OCULAR SURGERIES:
EYE (RIGHT/LEFT/BOTH)
PROCEDURE
SURGEON
HAVE YOU EVER HAD ANY TYPE OF SURGERY:
PROCEDURE
DATE OF SURGERY
DATE OF SURGERY