Vision Specialists Orange County | Eye Care California

MEDICAL HISTORY QUESTIONNAIRE

Date: / /

Name:

Date of Birth:

Date of last eye exam:

List any medications you currently take (Rx and over-the-counter):

Do you have allergies to any medications? YES NO

If YES, list the medications:

List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, etc.) or injuries (concussion, etc.):

List any surgeries you have had (cataract, lasik, appendectomy):

Do you currently have any problems in the following areas? If YES, please provide additional information.

General/Constitutional (fever, heat stroke, weight loss/gain, unusually tired)
YES NO

Details

Ears, Nose, Throat (hard of hearing, cold, earache, cough, dry mouth, etc.)
YES NO

Details

Cardiovascular (high BP, racing pulse, etc.)
YES NO

Details

Respiratory (congestion, wheezing, short of breath, etc.)
YES NO

Details

Gastrointestinal (stomach upset, diarrhea, constipation, hernia, ulcers, etc.)
YES NO

Details

Genital, Kidney, Bladder (painful/frequent urination, impotence, etc.)
YES NO

Details

Females Are you pregnant? Nursing?
YES NO

Details

Muscles, Bones, Joints (joint pain, stiffness, swelling, cramps, arthritis, etc.)
YES NO

Details

Skin (pimples, warts, growths, rash, etc.)
YES NO

Details

Neurological (numbness, headache, seizures, paralysis, etc.)
YES NO

Details

Psychiatric (anxiety, depression, insomnia)
YES NO

Details

Endocrine (diabetes, hypothyroid, etc.)
YES NO

Details

Blood/Lymph (bleeding, cholesterolemia, anemia, etc.)
YES NO

Details

Allergic/Immunologic (sneezing, swelling, redness, itching, hives, lupus, etc.)
YES NO

Details

FAMILY HISTORY
(Mother, Father, Grandparent, Sibling)
Has any member of your family had these diseases (circle all that apply)

YES NO UNKNOWN

Blindness
Cataract
Glaucoma
Diabetes
Hypertension

Heart Disease
Stroke
Cancer
Thyroid Disease
Other heritable disease:

SOCIAL HISTORY

Does your vision limit any activities of daily living (driving, reading, sports, work, etc?)

YES NO

Do you drink alcohol? YES NO

If YES, how much?

Do you smoke? YES NO

If YES, how much?

How many years?

Name of Primary
Care Physician:

Phone:

Name of Optometrist or
Ophthalmologist:

Phone:

Date: / /

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