• Medical History Questionnaire

  • Today’s Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Reason for Today’s Visit (Please check all that apply.)

  • Dilation: For an important and thorough view of the back of the eye, we instill drops which cause your pupils to enlarge. The drops require about 30 minutes to take effect. Afterwards, you will be sensitive to bright lights and you may have difficulty focusing on close objects. The effect may last for 4 hours.

  • Do you wish to be dilated today?

  • Retinal Photography: The doctor would like to take a picture of the back of the eye. These images help us to identify, compare, and monitor your internal eye health. They are used as a baseline to compare any changes to your eye health on a yearly basis, and identify problems due to diabetes, glaucoma, high blood pressure, and hardening of the arteries. This test is highly recommended and is available for an additional fee of $45.00 .

  • Would you like these pictures to be taken and included in your permanent records?

  • Medical History

  • Do you take any medications?
  • Do you have any allergies to medications?
  • Check any of the following that you have had
  • Are you pregnant or nursing?
  • Do you wear glasses?
  • Do you wear contact lenses?
  • Type of contact lenses
  • Are they comfortable?

  • Family History: 
    Please notate parents, grandparents, sibling, or children for the following conditions. 

  • Disease/Condition
    Rows

  • Social History: This information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer.

  • Yes, I would prefer to discuss my Social History information directly with my doctor?
  • Do you drive?
  • If yes , do you have visual difficulty when driving?
  • Do you use tobacco products?
  • Do you drink alcohol?
  • Do you use illegal drugs?
  • Have you ever been exposed to or infected with:

  • Review of system: Do you currently, or have you ever had any problem in the following areas?

  • Constitution:
    Rows
  • Integumentary:
    Rows
  • Neurological
    Rows
  • Eyes
    Rows
  • Endocrine
    Rows
  • Ears, Nose, Mouth, Throat
    Rows
  • Respiratory
    Rows
  • Vascular/Cardiovascular
    Rows
  • Gastrointestinal
    Rows
  • Genitourinary
    Rows
  • Bones/ Joint/ Muscles
    Rows
  • Lymphatic/ Hematology
    Rows
  • Allergic/Immunologic
  • Psychiatric
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: