Medical History Questionnaire
Medical History
Do you have any allergies to medications?
Are you pregnant or nursing?
Do you wear glasses?
Do you wear contact lenses?
Type of contact lenses:
Are they comfortable?
Do you use a computer?
Viewing distance to monitor
to reference material
Eye History — Do you currently have or have had in the past?
Family History — parents, grandparents, siblings, children (living or deceased)
Blindness
Heart Disease
Cataract / Surgery
High Blood Pressure
Crossed Eyes
Kidney Disease
Glaucoma
Thyroid Disease
Macular Degeneration
Diabetes
Retinal Detachment
Cancer
Arthritis
Other
Social History
This information is kept strictly confidential. You may discuss this directly with the doctor if you prefer.
Do you drive?
If yes, difficulty driving?
Smoking
Alcohol
Drug Use
Exposed to or infected with:
Review of Systems (Chronic Only)
Constitutional
Dermatological
Neurological
Respiratory
Vascular / Cardiovascular
Gastrointestinal
Psychiatric
Genitourinary
Bones / Joints / Muscles
Lymphatic / Hematologic
Endocrine
Ears, Nose, Mouth, Throat
Allergic / Immunologic