Medical History Questionnaire
Medical History
Do you have any allergies to medications?
No
Yes
If yes, explain: _______________________________________
______________________________________________________________________________________________________
List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies):
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
List all major injuries, surgeries and/or hospitalizations you have had: _____________________________________________
______________________________________________________________________________________________________
List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease,
cataracts, eye infections or eye injury: ________________________________________________________________________
Do you wear glasses?
Do you use tobacco products?
Do you drink alcohol?
Do you use illegal drugs?
No Yes Do you wear contact lenses?
No
Yes
No Yes If yes, type/amount/how long: ___________________________________________
No Yes If yes, type/amount/how long: ___________________________________________
No Yes If yes, type/amount/how long: ___________________________________________
Review of Systems
Do you currently, or have you ever had any problems in the following areas (Please check column Yes or No):
SYSTEM
Constitutional-Fever, Weight Loss/Gain
Integumentary-Skin
Neurological- Headaches, Migraines,
seizures
Psychiatric
Genitourinary- Genitals, Kidney,
bladder
Lymphatic/Hematologic- Anemia,
Bleeding Problems
Allergic Immunologic
Eyes- Dryness, Mucous Discharge,
Redness, Sandy or Gritty Feeling,
Itching, Burning
Eyes-Eye Pain or soreness, chronic
infection of eye or lid
NO
YES
SYSTEM
Ears, Nose, Mouth, Throat- Allergies/Hay Fever
Respiratory- Asthma, Chronic Bronchitis,
Emphysema
Vascular/Cardiovascular- Diabetes, Heart Pain,
High Blood Pressure, High Cholesterol, Vascular
disease
Endocrine- Thyroid/Other Glands
Gastrointestinal- Diarrhea/Constipation
NO
YES
Bones, Joints, Muscles- Rheumatoid Arthritis,
Muscle pain, Joint Pain
Eyes-Loss of vision, Blurred vision, Distorted
Vision/Halos, Loss of side Vision, Double vision
Eyes- Foreign body sensation, Excessive
tearing/watering, Glare/light sensitivity
Eyes-Sties or Chalazion, Flashes/Floaters in Vision,
Tired eyes
Family History –Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following
conditions:
No
Yes
Relationship to you
Disease/Condition
Blindness
Crossed eyes
Glaucoma
Macular Degeneration
Retinal Detachment Disease
Diabetes
________________________________________________________
__________________________
Doctor’s Signature
Date