EyeMax Medical History Questionnaire

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Healthcare Reform Requirement as of Fall 2011 (Please check one for each section):
  • Please note: Spouse (w or h) or Parents (p), Children (c) or Siblings (s):
    Please also note Name(s) and Age(s)
  • Medical History

  • Family History

    Please note any family history (specify parents, maternal/paternal grandparents, siblings, children [living or deceased]) for the following conditions:
  • Social History
    This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
  • Healthcare Reform Requirement as of Fall 2011
  • Review of Systems

    Do you currently have, or have you ever had any problems in the following areas:
  • SYSTEM CONSITITUTIONAL
  • NEUROLOGICAL
  • EYES
  • ENDORINE
  • EARS, NOSE, MOUTH, THROAT
  • RESPIRATORY
  • VASCULAR/CARDIOVASCULAR
  • GASTROINTESTINAL
  • GENITOURINARY
  • BONES/JOINTS/MUSCLES
  • LYMPHATIC/HEMATOLOGIC
  • * 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.