EyeMax Medical History Questionnaire

Name:

First Middle Last

Appt Date:

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:

Age:

Social Security Number:

Last Eye Exam:

Name of Medical Doctor:

Last Medical Exam:

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.