EyeMax Medical History Questionnaire

EyeMax Medical History Questionnaireadmin2018-02-19T05:13:39+00:00

EyeMax Medical History Questionnaire

Name:
First Middle Last
Appt Date:
Date Format: MM slash DD slash YYYY
Email address:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (Home):
Phone (Work):
Phone (Cell):
Preferred Contact Number (check):
- Home
- Work
- Cell
Birth Date:
Date Format: MM slash DD slash YYYY
Age:
Social Security Number:
Last Eye Exam:
Date Format: MM slash DD slash YYYY
Name of Medical Doctor:
Last Medical Exam:
Date Format: 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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EyeMax Medical History Questionnaire

Medical History

Family History

Review of Systems