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Home » Our Eye Care Clinic » Patient Forms » Medical History Questionnaire

Medical History Questionnaire

  • (Required for new patients and returning patients that have not been seen during the last three years)

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • MEDICAL HISTORY

  • MedicationReaction 
  • MedicationDosageFrequency Taken 
  • FAMILY HISTORY

    Please note any family history for the following conditions.
    Relatives can be parents, grandparents, siblings, children: living or deceased.
  • SOCIAL HISTORY

  • REVIEW OF SYSTEMS

    Do you currently, or have you ever had any problems in the following areas?
  • NoYes
    Extreme Weight Loss or Gain
    Integumentary (Skin)
  • NoYes
    Headaches
    Migraines
    Seizures
  • NoYes
    Loss of Vision
    Blurred Vision
    Distorted Vision/Halos
    Loss of Side Vision
    Double Vision
    Dryness
    Mucous Discharge
    Redness
    Sandy or Gritty Feeling
    Itching
    Burning
    Foreign Body Sensation
    Excess Tearing/Watering
    Glare/Light Sensitivity
    Eye Pain or Soreness
    Chronic Infection, Eye or Lid
    Sties or Chalazion
    Flashes/Floaters in Vision
    Tired Eyes
  • NoYes
    Thyroid
    Elevated Cholesterol
    Cancer
  • NoYes
    Sinus Congestion
    Chronic Cough
    Dry Throat/Mouth
    Allergies/Hay Fever
  • NoYes
    Asthma
    Chronic Bronchitis
    Emphysema
  • NoYes
    Diabetes
    Heart Pain
    High Blood Pressure
    Vascular Disease
    Heart Disease
    Diabetic Suspect
  • NoYes
    Colitis
    Acid Reflux
    Crohn's Disease
  • NoYes
    Kidney/Bladder
  • NoYes
    Rheumatoid Arthritis
  • NoYes
    Anemia
    Bleeding Problems
  • NoYes
    Lupus
    Fibromyalgia
  • NoYes
    Depression
    Anxiety
    BiPolar Disorder
  • Date Format: MM slash DD slash YYYY

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