MARSHALL EYECARE, LLC - Clay Street Eye Care

Medical History Questionnaire
Name: _______________________________________________ Sex: M F Date of Birth: ______/______/______
Address: _______________________________________ City: ___________________ State: ____ Zip: _________
Phone: ________________________ Work: _________________________ Cell: _____________________________
Occupation/Grade_________________________Employer/School___ ________________________________
Email Address:____________________________________________ Soc Sec #: _____________________________
Marital Status: ______________________________Spouse's Name: _____________________________________
(If under 18)Mother: ____________________________________ Father: _____________________________________________
Medical Insurance: __________________________________Medical Doctor __ ____________________________
Vision Insurance: ___________________________Policy Holder’s Name ___________________________
Policy Holder’s Soc Sec # ____________________Policy Holder’s Date of Birth _____________________
Policy Holder’s Place of Employment _______________________________
Allergies: List all known allergies.
Penicillin: Yes ( No ( Sulfa: Yes ( No ( Iodine: Yes ( No ( Seasonal allergies: Yes ( No (
Pain med: Yes ( No ( Type: ____________________ Other (please list): ______________________________
Medications: Please list below (or provide a list of) all medications, including eye drops & non-prescription drugs:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Review of Systems:
Do you currently have any of the following problems? Yes No If YES, please explain:
Heart Problems (chest pain, irregular heart beat) ( ( _____________________
Respiratory Problems (shortness of breath, wheezing, cough) ( ( _____________________
Gastrointestinal Problems (heartburn, abdominal pain, diarrhea) ( ( _____________________
Urinary Problems (pain or discomfort, blood in urine) ( ( _____________________,
Are you pregnant? ( ( _____________________
Skin Problems (rashes, excessive dryness, rosacea) ( ( _____________________
Musculoskeletal Problems (muscle aches, joint pain, swollen joints) ( ( _____________________
Neurological Problems (numbness, weakness, headaches, paralysis) ( ( _____________________
Psychiatric Problems (depression, anxiety) ( ( _____________________
Chronic fever, unexpected weight loss/gain, fatigue ( ( _____________________
Ear/nose/throat Problems (hearing loss, sinus problems, sore throat) ( ( _____________________
Endocrine Problems (diabetes, thyroid problems) ( ( _____________________
Blood disorders or immunologic compromise (anemia, HIV, AIDS) ( ( _____________________
Eye problems or injury: previously? í¯€ currently? í¯€ Explain: __________________________________________
Social History
Do you smoke? ( ( How much?________________
Do you drink alcohol? ( ( How much?________________
Family History
Have you or immediate family member (parent, grandparent, sibling) ever had any of the following conditions?
Self Family Self Family Self Family Self Family
Cataract ( ( High Blood Pressure ( ( Diabetes ( ( Migraines ( (
Glaucoma ( ( Heart Disease ( ( Asthma ( ( Seizure/Epilepsy ( (
Crossed/Lazy Eye ( ( Stroke ( ( Chronic Bronchitis ( ( Arthritis ( (
Retinal Detachment ( ( Heart Arrhythmia ( ( Sinus Problems ( ( Thyroid Disease ( (
Retinal Degeneration ( ( Anemia ( ( Tuberculosis ( ( Liver Disease ( (
Macular Degeneration ( ( High Cholesterol ( ( HIV / AIDS ( ( Cancer ( (
Blindness ( ( Explain: ___________________________________________________________
Surgeries & Illnesses: List any previous surgeries (including eye surgeries and laser procedures) or illnesses:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Hobbies Please list any hobbies you may have: ___________________________________________________________________
Patient (or Guardian) Signature: __________________________________________________________________ Date: ____/____/_____
Reviewed by patient on ____/____/_____ Pt Initials________ Reviewed by patient on ____/____/_____ Pt Initials________
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