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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