MEDICAL HISTORY QUESTIONNAIRE

Name Date Family Doctor

Date of birth Date of last eye exam

List any medications you are currently taking (prescription or nonprescription)

Do you have any drug or food allergies? (Please list type or reaction) yes no

If yes, please list

List all major illnesses or injuries

List any surgeries you have had

Do you have any problems in the following areas?

  Yes No If yes please explain
Eyes
General/Constitutional
(Fever, Weight loss, Other)
Ears, Nose & Throat
(Sinus, Ear infection, Chronic Cough, dry mouth)
Cardiovascular
(Heart and Blood vessels)
Respiratory
(Asthma, Emphysema, COPD)
Gastrointestinal
(Stomach, Ulcers, Intestinal disease, Etc.)
Genital, Kidney, Bladder
Muscles, Bone or Joints
(Arthritis)
Skin
Neurological
(Brain, Nervous System)
Psychiatric
(Anxiety, Depression, Insomnia)
Endocrine
(Diabetes, Thyroid, Etc.)
Blood/Lymph
(High Cholesterol, Anemia, HIV)
Allergic/Immunologic
(Hay fever, Lupus, Sjogrens)

Family History

M= Mother F= Father S= Sibling GP= Grandparent
  Yes No If yes please explain
Blindness
Glaucoma
Cataracts
Macular Degeneration
Retinal Detachment
Diabetes
Arthritis
Cancer
Heart Disease
High Blood Pressure
Kidney Disease
Lupus
Thyroid Disease
HIV Infection
Other

Social History

Current Occupation

Education

Hobbies

Do you drive? yes no

Do you have visual difficulty when driving? yes no

Do you have problems with night vision? yes no

Do you have trouble reading or when doing close work? yes no

Do you currently wear glasses? yes no

Do you wear contact lenses? yes no

Are you interested in contact lenses? yes no

How old is your current prescription for glasses or contact lenses?

Do you drink alcohol or use recreational drugs? yes no
If yes, how much

Do you smoke? yes no , If yes, how much

Have you ever had a blood transfusion? yes no , If yes, when