MEDICAL HISTORY QUESTIONAIRRE
FORT WORTH EYE ASSOCIATES
PLEASE FILL OUT COMPLETELY
NAME: _______________________________Date of Birth: __________________________
MEDICAL HISTORY QUESTIONNAIRE
DRUG ALLERGIES: ________________________________________________ □ NONE
PLEASE CHECK ONLY CONDITIONS/ SYMPTOMS THAT YOU ARE CURRENTLY EXPERIENCING OR HAVE HAD IN THE PAST:
Constitutional: Respiratory: Integumentary: Immunologic:
□ Fatigue □ Shortness of □ Acne □ Food allergies
□ Fever breath □ Rosacea □ Seasonal allergies
□ Weight Loss □ Wheezing □ Rash □ Immune disorders
□ Chills □ Cough □ Change in hair □ NONE
□ Sweats □ Difficulty texture
□ NONE breathing □ Change in nails Endocrine:
□ NONE □ Skin cancer □ Diabetes
□ NONE □ Thyroid disorder
E N T: Gastrointestinal: □ Hypoglycemia
□ Dry Mouth □ Reflux Musculoskeletal: □ Memory loss
□ Earache □ Diarrhea □ Gout □ NONE
□ Nasal congestion □ Nausea □ Arthritis
□ Nosebleeds □ Vomiting □ Joint pain Psychiatric:
□ Sore throat □ Indigestion □ Back pain □ Depression
□ Sinus pain □ Constipation □ NONE □ Panic disorder
□ Chronic cough □ Ulcers □ Anxiety
□ NONE □ NONE Neurological: □ NONE
□ Dizziness
Cardiovascular: Genitourinary: □ Headaches Other:
□ Chest pain □ Urination □ Slurred speech □ Pregnant or
□ Palpitations □ STD □ Memory loss Breastfeeding
□ Leg edema □ Kidney ailment □ Gait disturbance □ Other
□ Increased heart rate □ NONE □ Swollen glands ___________
□ Stroke □ Loss of
□ Heart attack coordination
□ High Blood pressure □ NONE
□ High Cholesterol
□ NONE Hematologic:
□ Enlarged lymph nodes
□ Abnormal bleeding
□ Swollen glands
□ NONE
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