Medical history questionnaire

Name __________________________________________________
Date ____________
Date of birth _____________________ Date of last eye exam ______________________ Referring Dr. ______________________________ Primary Care Physician __________________________ What is the chief complaint regarding your eyes?________________________________________________ _______________________________________________________________________________________ List any medications you currently take (prescription and over-the-counter):___________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Do you have allergies to any medications? □ YES □ NO If YES, list the medications:__________________ _______________________________________________________________________________________ Have you ever taken Mellaril (Thioridazine), Chloroquine, Plaquenil, or Tamoxifen? List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, etc.) or injuries (concussion,
________________________________________________________________________________________________ ________________________________________________________________________________________________ List any surgeries you have had (cataract, tonsils, appendix, etc.) _______________________________________ ________________________________________________________________________________________________ Do you currently have any of the problems below? If YES, please give details: NO EXPLANATION OF PROBLEM
GENERAL/CONSTITUTIONAL (Fever)
(Weight loss)
EARS, NOSE, THROAT (Sinus infections)
(ear infection, chronic cough, dry mouth)
CARDIOVASCULAR (Heart Attack)
(High blood pressure)
RESPIRATORY (Asthma)
(Emphysema)
GASTROINTESTINAL (Stomach ulcers)
(Hepatitis)
GENITAL, KIDNEY (Kidney stones)
(Dialysis)
MUSCLES, BONES, JOINTS (Arthritis)
(Polymyalgia rheumatica)
SKIN (Acne, warts, skin cancer)
NEUROLOGICAL (Stroke)
(Multiple sclerosis)
ENDOCRINE (thyroid)
Diabetes [how long?]
BLOOD/LYMPH ( Cholesterol, anemia)
(Taking blood thinners)
INFECTIOUS DISEASE (Syphilis, TB, HIV)
ALLERGIC/IMMUNOLOGIC (Lupus, Sjogrens)
FAMILY HISTORY
M=Mother, F=Father, S=Sibling, GP=Grandparents
SOCIAL HISTORY
Current or prior occupation:__________________________________________________________________ Education (high school, vocational school, college degree):_________________________________________ Marital Status (married, divorced, single, widowed):_______________________________________________ Living Arrangements:_______________________________________________________________________Do you drive? Do you have visual difficulty when driving? □ YES □ NO If YES: occasional 1 per day 2-3/day 4+/day □ YES □ NO If YES: occasional 1 per day 2-3/day 4+/day Physician’s Signature:_____________________________________________ Date:____________________

Source: http://www.californiaretina.com/files/Medical%20History%20Questionnaire.pdf