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EyeMax Medical History Questionnaire
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2018-02-19T05:13:39+00:00
EyeMax Medical History Questionnaire
Name:
First
Middle
Last
Appt Date:
MM slash DD slash YYYY
Email address:
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone (Home):
Phone (Work):
Phone (Cell):
Preferred Contact Number (check):
Home
Work
Cell
Birth Date:
MM slash DD slash YYYY
Age:
Social Security Number:
Last Eye Exam:
MM slash DD slash YYYY
Name of Medical Doctor:
Last Medical Exam:
MM slash DD slash YYYY
Employer:
Occupation:
How were you referred to our office?
Preferred Contact Method (check):
Phone
Email
Text
Postal
Healthcare Reform Requirement as of Fall 2011
(Please check one for each section):
Race:
American Indian/Alaskan Native
Black/African American
Hispanic
Native Hawaiian/Other Pacific Island
White
Ethnicity:
Hispanic/Latino
Native Hawaiian/Other Pacific Island
Not Hispanic/Latino
Preferred Language:
English
Spanish
Family Members Living at Home
Please note: Spouse (w or h) or Parents (p), Children (c) or Siblings (s):
Please also note Name(s) and Age(s)
Medical History
Do you have any allergies to medications?
No
Yes
If Yes, explain:
List all major injuries, surgeries and/or hospitalizations you have had:
List any of the following that you have had: crossed eyes, lazy eyes, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections, or eye injury:
Are you pregnant and/or nursing?
No
Yes
Do you wear glasses:
No
Yes
Do you wear contact lenses?
No
Yes
Type of contact lenses:
Rigid
Soft
Extended Wear
Other
Are they comfortable?
No
Yes
Brand of contacts:
Prescription for right eye:
Prescription for left eye:
Family History
Please note any family history (specify parents, maternal/paternal grandparents, siblings, children [living or deceased]) for the following conditions:
Blindness
No
Yes
?
Relationship to you:
Cataract
No
Yes
?
Relationship to you:
Crossed Eyes
No
Yes
?
Relationship to you:
Glaucoma
No
Yes
?
Relationship to you:
Macular Degeneration
No
Yes
?
Relationship to you:
Retinal Detachment/Disease
No
Yes
?
Relationship to you:
Arthritis
No
Yes
?
Relationship to you:
Cancer
No
Yes
?
Relationship to you:
Diabetes
No
Yes
?
Relationship to you:
Heart Disease
No
Yes
?
Relationship to you:
High Blood Pressure
No
Yes
?
Relationship to you:
Kidney Disease
No
Yes
?
Relationship to you:
Lupus
No
Yes
?
Relationship to you:
Thyroid Disease
No
Yes
?
Other
Relationship to you:
Social History
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
I would like to discuss my Social History information directly with my doctor, rather than filling out below.
Yes
No
Do you drive?
No
Yes
If yes, do you have visual difficulty when driving?
No
Yes
If yes, please describe:
Do you use tobacco products?
No
Yes
If yes, type/amount/how long?
Do you drink alcohol?
No
Yes
If yes, type/amount/how long?
Do you use illegal drugs?
No
Yes
If yes, type/amount/how long?
Have you ever been exposed to or infected with:
Gonorrhea
Hepatitis
HIV
Syphilis
None
Healthcare Reform Requirement as of Fall 2011
Height:
Weight:
Review of Systems
Do you currently have, or have you ever had any problems in the following areas:
SYSTEM CONSITITUTIONAL
Fever, Weight Loss/Gain
No
Yes
?
INTEGUMENTARY (Skin)
No
Yes
?
NEUROLOGICAL
Headaches
No
Yes
?
Migraines
No
Yes
?
Seizures
No
Yes
?
EYES
Loss of Vision
No
Yes
?
Blurred Vision
No
Yes
?
Distorted Vision
No
Yes
?
Loss of Side Vision
No
Yes
?
Double Vision
No
Yes
?
Dryness
No
Yes
?
Mucous Discharge
No
Yes
?
Redness
No
Yes
?
Sandy or Gritty Feeling
No
Yes
?
Itching
No
Yes
?
Burning
No
Yes
?
Foreign Body Sensation
No
Yes
?
Excess Tearing/Watering
No
Yes
?
Glare/Light Sensitivity
No
Yes
?
Eye Pain or Soreness
No
Yes
?
Chronic Infection of Eye or Lid
No
Yes
?
Sties or Chalazion
No
Yes
?
Flashes/Floaters in Vision
No
Yes
?
Tired Eyes
No
Yes
?
ENDORINE
Thyroid/Other Glands
No
Yes
?
Diabetes
No
Yes
?
EARS, NOSE, MOUTH, THROAT
Allergies/Hay Fever
No
Yes
?
Sinus Congestion
No
Yes
?
Runny Nose
No
Yes
?
Post-Nasal Drip
No
Yes
?
Chronic Cough
No
Yes
?
Dry Throat/Mouth
No
Yes
?
RESPIRATORY
Asthma
No
Yes
?
Chronic Bronchitis
No
Yes
?
Emphysema
No
Yes
?
VASCULAR/CARDIOVASCULAR
High Cholesterol
No
Yes
?
Heart Pain
No
Yes
?
High Blood Pressure
No
Yes
?
Vascular Disease
No
Yes
?
GASTROINTESTINAL
Diarrhea
No
Yes
?
Constipation
No
Yes
?
GENITOURINARY
Genitals/Kidney/Bladder
No
Yes
?
BONES/JOINTS/MUSCLES
Rheumatoid Arthritis
No
Yes
?
Muscle Pain
No
Yes
?
Joint Pain
No
Yes
?
LYMPHATIC/HEMATOLOGIC
Anemia
No
Yes
?
Bleeding Problems
No
Yes
?
ALLERGIC/IMMUNOLOGIC
No
Yes
?
PSYCHIATRIC
No
Yes
?
If you answered YES to any of the above or have a condition not listed, please explain:
List any medication you take (including oral contraceptives, aspirin, over the counter medications, and move remedies):
* If you prefer to provide a written list you will bring with you, please inform our technicians and we will be happy to attach a copy to your records.
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