MEDICAL HISTORY QUESTIONNAIRE

* Required fields.

* Name *Date of Birth Age

Height Weight Family Doctor

Date of last eye exam : Were you referred by a physician or optometrist ? Yes No If yes explain

List all medications with dosage and strength (prescription and over-the-counter) or select NONE:

Do you have any allergies to any medications? Yes No. If yes, please list :

List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack) or injuries (concussion, etc.) or select NONE:

List any surgeries you have had (cataract, tonsillectomy, appendectomy, ect.) or select NONE:

Self / Family History SE=Self M = Mother F = Father SI = Sibling , GP = Grandparent

Do you or any members of your family have any eye disorders ?

Y N Who? Explain   Y N Who? Explain Amblyopia (lazy eye) SMFSIGP Diabetic Retinopathy S M F SI GP Glaucoma S M F SI GP Retinal Detachment S M F SI GP Cataracts S M F SI GP Dry Eye S M F SI GP Age Related Macular Degeneration S M F SI GP Cornea S M F SI GP           Other S M F SI GP

Do you or any members of your family have any general health problems?

Y N Who? Explain   Y N Who? Explain Ears, Nose, Throat (Sinus, ear infection, chronic cough, dry mouth, etc.) S M F SI GP Skin (Acne, warts, skin cancer, etc.) S M F SI GP Cardiovascular (Heart, vessels, etc.) S M F SI GP Neurological (Multiple sclerosis, etc.) S M F SI GP Respiratory (Asthma, emphysema, etc.) S M F SI GP Psychiatric (Anxiety, depression, insomnia, etc.) S M F SI GP Gastrointestinal (Stomach ulcers, intestinal disease, etc.) S M F SI GP Endocrine (Diabetes, hypothyroid, etc.) S M F SI GP Genital, Kidney, Bladder S M F SI GP Blood/Lymph (Cholesterolemia, anemia, etc.) S M F SI GP Muscles, Bones, Joints (Arthritis, etc.) S M F SI GP Allergic/Immunologic (Hay fever, lupus, Sjogrens, etc.) S M F SI GP

Social History

Current occupation : Living Arrangements ? Independent Skilled Nursing Home Marital Status : Single Married Divorced Widowed Do you Drive ? Yes No Do you currently wear glasses ? Yes No Do you have visual difficulty when driving ? Yes No If yes, how long have you had the current prescription ? Do you have problems with night vision ? Yes No Do you wear contacts ? Soft Toric Gas Perm Do you drink alcohol ? Yes No     How Much ? How many hours per day ? How many years ? Do you smoke ? Yes No              How Much ?

Enter Your Name Date

DJS GOW MB RAM Date