Medical History Questionnaire (Required for new patients and returning patients that have not been seen during the last three years) Location*LenexaLee's SummitToday's Date: MM slash DD slash YYYY Name: First Middle Last Home Phone:Work Phone:Cell Phone:Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Would you like text notifications? Yes No Employer: Occupation: Email: Birth Date: MM slash DD slash YYYY Social Security #: Race/Ethnicity: Preferred Language: Gender: Male Female Who may we thank for referring you to our office? Name of Medical Doctor: City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Where was your last eye exam? Marital Status: Spouse or Guardian (If Applicable): Current Height: Current Weight: Reason for visit:How would you like your prescription?* Paper Electronic (If electronic it will be sent to you through unencrypted email which is not secure and does not guarantee privacy. Do you still want it sent to you electronically?) MEDICAL HISTORYDo you have any allergies to medications? No Yes If yes, list medication(s) & reaction below:MedicationReaction Do you have any non-medication allergies? No Yes If yes, what? List any medications you take (including oral contraceptives, aspirin, OTC medications, etc):MedicationDosageFrequency Taken List all major injuries, surgeries, and/or hospitalizations you have had: Check any of the following that you have: Crossed Eyes Lazy Eye Drooping Eyelid Prominent Eyes Cataracts Glaucoma Iritis/Uveitis Eye Injury Macular Degeneration Retinal Disease or Detachment Eye Infections Keratoconus Corneal Problems Other Eye Disorders If other, please specify: Are you pregnant? No Yes Are you nursing? No Yes Do you wear glasses? No Yes If yes, how old is your present pair of glasses? Do you wear contact lenses? No Yes If yes, how old is your present pair of lenses? What brand of contacts do you wear? Type of contact lenses: Rigid Soft Extended Wear Other Are they comfortable? Yes No FAMILY HISTORYPlease note any family history for the following conditions. Relatives can be parents, grandparents, siblings, children: living or deceased.<br/? When listing relationship, if a grandparent, please specify maternal or paternal.Blindness No Yes Relationship to you: Cataract No Yes Relationship to you: Crossed Eyes No Yes Relationship to you: Glaucoma No Yes Relationship to you: Macular Degeneration No Yes Relationship to you: Retinal Detachment or Disease No Yes Relationship to you: Cancer No Yes Please specify the type of cancer and the relationship to you: Diabetes No Yes Relationship to you: Heart Disease No Yes Relationship to you: High Blood Pressure No Yes Relationship to you: Kidney Disease/Stones No Yes Relationship to you: Lupus No Yes Relationship to you: Thyroid Disease No Yes Relationship to you: Arthritis No Yes Relationship to you: Other No Yes Please specify condition and relationship to you: SOCIAL HISTORYDo you smoke? No Yes Are you a former smoker? No Yes Do you drink alcohol? No Yes If yes: Daily Weekly Rarely Do you use illegal drugs? No Yes REVIEW OF SYSTEMSDo you currently, or have you ever had any problems in the following areas?ConstitutionalNoYesExtreme Weight Loss or GainIntegumentary (Skin)NeurologicalNoYesHeadachesMigrainesSeizuresEyesNoYesLoss of VisionBlurred VisionDistorted Vision/HalosLoss of Side VisionDouble VisionDrynessMucous DischargeRednessSandy or Gritty FeelingItchingBurningForeign Body SensationExcess Tearing/WateringGlare/Light SensitivityEye Pain or SorenessChronic Infection, Eye or LidSties or ChalazionFlashes/Floaters in VisionTired EyesEndocrineNoYesThyroidElevated CholesterolCancerIf cancer, please specify type: Ears, Nose, Mouth, ThroatNoYesSinus CongestionChronic CoughDry Throat/MouthAllergies/Hay FeverRespiratoryNoYesAsthmaChronic BronchitisEmphysemaVascular/CardiovascularNoYesDiabetesHeart PainHigh Blood PressureVascular DiseaseHeart DiseaseDiabetic SuspectGastrointestinalNoYesColitisAcid RefluxCrohn's DiseaseGenitourinaryNoYesKidney/BladderMusculoskeletalNoYesRheumatoid ArthritisLymphatic/HematologicNoYesAnemiaBleeding ProblemsAllergic/ImmunologicNoYesLupusFibromyalgiaPsychiatricNoYesDepressionAnxietyBiPolar DisorderIf you answered yes to any of the above or have a condition not listed, please explain and list medications: Patient SignatureDate MM slash DD slash YYYY
