Advanced Vision Instıtute

Confidential Medical History Questionnaire

Name: Date of Birth: Date:

Do any of the conditions listed below apply to you or your immediate family?
Please check the appropriate column(s).

Eyes You Family Lungs You Family
Decreased distance vision Asthma
Decreased near vision Emphysema
Distorted vision Shortness of Breath
Loss of side vision Tuberculosis
Double vision Wheezing
Fluctuating vision Chronic cough
Tired eyes      
Flashing lights Heart You Family
Glare/light sensitivity Heart attack
Night blindness Irregular heart beat
Floaters Hypertension
Headache Pacemaker
Dryness Coronary artery bypass graft
Mucous discharge Congestive heart disease
Redness Chest pains
Sandy or gritty feeling      
Itching Nervous System You Family
Burning Blackout
Foreign body sensation Migraine
Pain or soreness Stroke
Infection of eye or lid Palsy
Sties, Chalazion Seizures
Cataract      
Glaucoma General You Family
Retinal disorder HIV
Macular degeneration Fever
Strabismus Weight Loss
Blindness Lupus
      Cancer:    
Ear, Nose, Throat     type(s)    
Hearing loss    
Dizziness    
Sinus Congestion    
Runny nose      
Dry mouth/throat Osteoarthritis
Hoarseness Rheumatoid Arthritis
Sjogren's Syndrome      
           
Blood/Lymph systems You Family      
Bleeding nose, skin, internal      
Blood disorder      
Anemia      
Slow clotting time      
Swollen lymph nodes      
           
Stomach/Intestines You Family      
Hepatitis      
Gallstones      
Diarrhea      
Heartburn      
           
Urinary You Family      
Kidney disorder      
Kidney stones      
Herpes simplex      
Change in urination      
           
Pregnancy Yes No   Yes No
Are you currently pregnant? Are you presently nursing?

Drug Allergies:

Name of Current Medications:

List of Surgery and Dates (Women, please include C-Sections):

Date of Last Physical Exam
Name of Medical Doctor

 
REV 5/2013