Medical History Questionaire Template
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1
2MEDICAL HISTORY QUESTIONAIRE
FORM 3
Patient Name:
Today's Date:
Medical Doctor:
City / State:
Previous Eye Doctor:
City / State:
Last Eye Exam:
Month
Year
Type of glasses?
Do you wear glasses?
If Yes, age of your current Rx?
Do you wear contacts?
If Yes, age of your current lenses?
Type of contacts?
Right Eye:
What brand of contact lenses do you wear?
Left Eye:
How often do you replace your contacts?
PERSONAL MEDICAL HISTORY: (Review of Systems)
(Please check all that apply and enter other condition if applicable.)
Have you ever been diagnosed with any of the following MEDICAL conditions?
NEUROLOGIC
CARDIOVASCULAR
GASTROINTESTINAL
IMMUNOLOGIC
Elevated Cholesterol
Cancer: Colon / Liver
Histoplasmosis
Bell's Palsy
Heart Disease
Inflammatory Bowel (IBS)
Sjogren's Syndrome
Headaches/Migraines
Hypertension
Other:
Other:
Multiple Sclerosis
GENITOURINARY
INTEGUMENTARY (SKIN)
Stroke (CVA)
Myasthenia Gravis
Other:
Cancer: Prostate / Kidney
Basal/Squamous Cell Carcinoma
Other:
EAR, NOSE, MOUTH, THROAT
PSYCHIATRIC
Cancer: Ovarian / Uterine
Rosecea: Acne / Ocular
Other:
Other:
Other:
Other:
ENDOCRINE
HEMATOLOGIC/LYMPHATIC
MUSCULOSKELETAL
RESPIRATORY
Diabetes Mellitus
Cancer: Breast
Arthritis: Osteo/Rheumatoid
Asthma/Bronchitis/COPD
Thyroid Disease
Leukemia / Lymphoma
Down's Syndrome
Cancer: Lung
Other:
Other:
Other:
Other:
PERSONAL OCULAR HISTORY:
(Please check all that apply and enter other condition if applicable.)
Have you ever been diagnosed with any of the following OCULAR conditions?
Amblyopia (Crossed / Lazy Eye)
Cataracts
Glaucoma
Retinal Detachment/Disease
Blindness
Diabetic Retinopathy
Macular Degeneration
Vitreal Floaters
Dry Eye Syndrome
Choroidal Nevus (Freckle)
Ocular Allergies
Other:
Have you ever had any surgeries on your EYES?
Yes
No
If Yes, please indicate what type and approximate Month/Year.
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