Medical History Questionnaire - First Eye Care

Patient Name: Mr.Mrs.Ms.Dr.

Birth Date*

Email*

Last Medical Exam:

Name of Medical Doctor:

Dr's Phone:

Last Eye Exam:

Last Eye Doctor:

Dr's Phone:

MEDICAL HISTORY

Do you have any allergies to medications:

YesNo

If yes, explain:

List any medications you take (including pills, creams, drops, oral contraceptives, aspirin, over-the-counter medications, and home remedies):

List all major injuries, surgeries, and/or hospitalizations you have had:

List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections, or eye injury:

Are you pregnant and/or nursing?

YesNo

If yes, how far along?

Do you wear glasses?

YesNo

If yes, how old is your present pair of lenses?

Do you wear contact lenses?

YesNo

If yes, how old is your present pair of lenses?

Type of contact lenses:

RigidSoftExtended Wear (sleep in)Other

Are they comfortable?

YesNo

FAMILY HISTORY

Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:

Disease/Condition

Relationship To You

Cataract

No Yes N/A

Relationship To You

Crossed Eyes

No Yes N/A

Relationship To You

Glaucoma

No Yes N/A

Relationship To You

Macular Degeneration

No Yes N/A

Relationship To You

Retinal Detachment/Disease

No Yes N/A

Relationship To You

Cancer

No Yes N/A

Relationship To You

Diabetes

No Yes N/A

Relationship To You

Heart Disease

No Yes N/A

Relationship To You

High Blood Pressure

No Yes N/A

Relationship To You

Thyroid Disease

No Yes N/A

Relationship To You

Other

No Yes N/A

Relationship To You

SOCIAL HISTORY

This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.

I would prefer to discuss my Social History information directly with my doctor

Do you drive?YesNoN/A

If yes, do you have visual difficulty when driving?

YesNoN/A

If yes, please describe:

Do you use tobacco products?YesNo
If yes, type/amount/how long?

Do you drink alcohol?YesNo
If yes, type/amount/how long?

Do you use illegal drugs?Yes No

If yes, type/amount/how long?

Have you ever been exposed to or infected with (check those that apply, if any):GonorrheaHepatitisHIVSyphilis

REVIEW OF SYSTEMS

System

If you answered YES to any of the above or have a condition not listed, please explain & list medications:

Doctor’s Signature

Date

MEDICAL HISTORY

FAMILY HISTORY

SOCIAL HISTORY

REVIEW OF SYSTEMS

System

System

CONSTITUTIONAL

INTEGUMENTARY (SKIN)

NEUROLOGICAL

EYES

ENDOCRINE

EAR, NOSE, MOUTH, THROAT

RESPIRATORY

VASCULAR/CARDIOVASCULAR

GASTROINTESTINAL

GENITOURINARY

BONES/JOINTS/HEMATOLOGIC

LYMPHATIC/HEMATOLOGIC

ALLERGIC/IMMUNOLOGIC

PSYCHIATRIC

Hurst

Keller

Roanoke

Our Locations

Hurst

Keller

Roanoke

Book an Appointment

MEDICAL HISTORY

FAMILY HISTORY

SOCIAL HISTORY

REVIEW OF SYSTEMS

System

System

CONSTITUTIONAL

INTEGUMENTARY (SKIN)

NEUROLOGICAL

EYES

ENDOCRINE

EAR, NOSE, MOUTH, THROAT

RESPIRATORY

VASCULAR/CARDIOVASCULAR

GASTROINTESTINAL

GENITOURINARY

BONES/JOINTS/HEMATOLOGIC

LYMPHATIC/HEMATOLOGIC

ALLERGIC/IMMUNOLOGIC

PSYCHIATRIC