MEDICAL HISTORY QUESTIONNAIRE
THE EYE INSTITUTE OF WYOMING, P.C.
NAME
*
TODAY’S DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of your last eye exam
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Previous Eye Doctor
Date of your last medical exam
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Medical Doctor
LIST ANY MEDICATION:
(INCLUDE ORAL CONTRACEPTIVES, ASPRINS, OTC MEDICATIONS, SUPPLEMENTS, AND HOME REMEDIES)
MEDICATION ALLERGIES:
Do you wear glasses?
Yes
No
How old are your glasses?
Do you wear contact lenses?
Yes
No
Brand of contacts?
How often do you replace your contacts?
Are your contacts comfortable?
Yes
No
Do you sleep in your contacts?
Yes
No
Type of cleaning solution?
Review of Systems
(Please indicate if you have ever had any problems with any of the following areas of your body)
CARDIOVASCULAR
Heart Disease/Pain
Yes
No
High Blood Pressure
Yes
No
Stroke
Yes
No
Vascular Disease
Yes
No
CONSTITUTIONAL
Weight Loss/Gain
Yes
No
Chronic Fever
Yes
No
EARS, NOSE, MOUTH, THROAT
Allergies
Yes
No
Sinus Congestion
Yes
No
Runny Nose
Yes
No
Chronic Cough
Yes
No
Dry Throat/Mouth
Yes
No
Throat Infection
Yes
No
ENDOCRINE
Thyroid
Yes
No
Diabetes
Yes
No
Hormone Therapy
Yes
No
EYES
Blurred Vision
Yes
No
Double Vision
Yes
No
Glare/Sensitivity
Yes
No
Burn/Itch
Yes
No
Flashes/Floaters
Yes
No
Pain/Discomfort
Yes
No
Redness
Yes
No
Dryness
Yes
No
Crossed/Lazy Eye
Yes
No
GASTROINTESTINOL
Diarrhea
Yes
No
Constipation
Yes
No
GENITOURINARY
Genitals
Yes
No
Kidney/Bladder
Yes
No
HEMATOLOGIC
Anemia
Yes
No
Bleeding Disorders
Yes
No
INTEGUMENTARY (SKIN)
Rash/Eczema
Yes
No
MUSCLE/JOINT/BONES
Arthritis
Yes
No
Muscle/Joint Pain
Yes
No
NEUROLOGICAL
Headaches/Migraines
Yes
No
Multiple Sclerosis
Yes
No
Head Trauma
Yes
No
Seizures
Yes
No
PHYCIATRIC
Nervous Disorders
Yes
No
RESPIRATORY
Asthma
Yes
No
Bronchitis
Yes
No
Emphysema
Yes
No
PREGNANT
Yes
No
OTHER
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Family History
(Parents, Grandparents, Siblings, Children) for the following
DISEASE/CONDITION
Rows
RELATIONSHIP TO YOU
Blindness
Cataracts
Crossed Eyes/ Lazy Eyes
Glaucoma
Macular Degeneration
Retinal Disease
Retinal Detachment
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Lupus
Stroke
Thyroid Disease
Other:
Social History
(This can be discussed confidentially with your doctor during the examination)
ACTIVITY
Rows
EXPLAIN
Do you use tobacco products?
Do you use alcohol?
Do you use illegal substances?
Have you ever been exposed to or infected with gonorrhea, hepatitis, HIV, or syphilis?
Do you live alone?
Yes
No
Do you drive?
Yes
No
Any visual difficulty when driving?
Yes
No
Check activities that you participate in:
Shooting
Running
Golf
Tennis
Biking
Sewing
Computer Work
Submit
Should be Empty: