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Medical History Questionnaire

Name:
Date:
Date of Birth:
Date of last eye exam:
List any medications you currently take (Rx and over the counter):
Do you have allergies to any medications?
If yes, please list:
List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, etc.) or injuries (concussion, etc.):
List any surgeries you have had (cataract, appendectomy, etc.):
If yes, please provide additional information:
Eyes (poor vision, eye pain, tearing, redness)
General/Constitutional (fever, heat stroke, weight loss or gain, unusually tired)
Ears, Nose, Throat (hard of hearing, stuffy nose, ear ache, cough, dry mouth, etc.)
Cardiovascular (high BP, racing pulse, etc.)
Respiratory (congestion, wheezing, shortness of breath, etc.)
Gastrointestinal (stomach upset, diarrhea, constipation, hernia, ulcers, etc.)
Genital, Kidney, Bladder (painful urination, frequent urination, impotence, yellow jaundice, etc.)
Females (Are you pregnant? Nursing?)
Muscles, Bones, Joints (joint pain, stiffness, swelling, cramps, arthritis, etc.)
Skin (pimples, warts, growths, rash, etc.)
Neurological (numbness, headache, seizures, paralysis, etc.)
Psychiatric (anxiety, depression, insomnia)
Endocrine (diabetes, hypothyroid, etc.)
Blood/Lymph (bleeding, cholesterolemia, anemia, problems related to blood transfusion, etc.)
Allergic/Immunologic (sneezing, swelling, redness, itching, hives, lupus, etc.)
Has any member of your family had these diseases (check all that apply)?
Has any member of your family had these diseases (check all that apply)?
Other heritable disease:
Does your vision limit any activities of daily living (driving, reading, sports, work, etc.)?
Have you ever had a blood transfusion?
Do you drink alcohol?
If yes, how much?
Do you smoke?
If yes, how much?
How many years?
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