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Medical History QuestionnairePatient Name: _____________________________ Patient Address ____________________________________________Patient Birthdate: _____ -______-_______ □ M □ F_________________________________________________________Today’s Date: _____________________________Date of Last Medical Exam: __________________________________ Home Phone: _____________________________Name of Medical Doctor and Phone Number:_____________________Work Phone: ______________________________________________________________________________________Cell Phone: _______________________________Insurance: Subscriber Name__________________________________Email: ___________________________________Subscriber Birthdate ___-___-_____ Last 4 of SS#______________MEDICAL HISTORYDo you have any allergies to medications? □ no □ yes If yes, explain: ______________________________________________________________________________________________________________________________________________________________________________________________________________________List any medications you take (including aspirin, over-the-counter medications, home remedies, and oral contraceptives).________________________________________________________________________________________________________________________________________________________________________________________________________________________List all major injuries, hospitalizations and/or surgeries you have had: ________________________________________________________________________________________________________________________________________________________________________________________________________________________Are you pregnant? □ no □ yes Are you nursing? □ no □ yesDo you wear glasses? □ no □ yes If yes, how old are your current lenses?______________________Do you wear contact lenses? □ no □ yes If yes, how old are your current lenses?______________________Type of contact lenses: □ Rigid □ Soft □ Extended Wear □ Other Are they comfortable? □ no □ yesFAMILY HISTORYPlease note any family history (parents/grandparents/siblings/children, living or deceased) for the following conditions:DISEASE/CONDITIONNO YES ? RELATIONSHIP TO YOU Blindness □ □ □ ___________________________Cataract □ □ □___________________________Crossed Eyes / Eye Turn □ □ □ ___________________________Drooping Eyelid □ □ □___________________________Eye Infection □ □ □ ___________________________Eye Injury □ □ □___________________________Glaucoma □ □ □___________________________Macular Degeneration □ □ □ ___________________________Retinal Detachment/Disease □ □ □___________________________Arthritis □ □ □ ___________________________Cancer □ □ □ ___________________________Diabetes □ □ □ ___________________________Heart Disease □ □ □ ___________________________High Blood Pressure □ □ □ ___________________________Kidney Disease □ □ □ ___________________________Lazy Eye □ □ □ ___________________________Lupus □ □ □___________________________Thyroid Disease □ □ □___________________________Other_____________________ □ □ □___________________________**PLEASE TURN FORM OVER AND COMPLETE OTHER SIDE**SOCIAL HISTORY This information is kept strictly confidential. However, you may discuss this portion with the doctor if you prefer. □ Yes, I would prefer to discuss my Social History information directly with my doctor. (Check box)Do you drive? □ no □ yesDifficulty when driving? □ no □ yes If yes, please describe: _______________________________________Do you use tobacco products? □ no □ yes If yes, type/amount/how long?_________________________________Do you drink alcohol? □ no □ yes If yes, type/amount/how long?_________________________________Do you have a history of substance abuse? If yes, type/amount/how long?______________________________Have you ever been exposed to or infected with: □ Gonorrhea □ Hepatitis □ HIV □ SyphilisREVIEW OF SYSTEMSDo you currently or have you ever had any problems in the following areas?SYSTEMNOYES? SYSTEMNOYES?CONSTITUTIONAL EARS, NOSE, MOUTH, THROATFever, Weight Loss/Gain □ □ □Allergies/Hay Fever □ □ □Sinus Congestion □ □ □ Runny Nose □ □□Post-Nasal Drip □ □ □NEUROLOGICALChronic Cough □ □□Headaches □ □□Dry Throat, Mouth □ □□Migraines □ □ □Seizures □ □ □RESPIRATORYAsthma □ □□EYESChronic Bronchitis □ □□Loss of Vision □ □□ Emphysema □ □ □Blurred Vision □ □ □ Distorted Vision/Halos □ □□ VASCULAR/CARDIOVASCULARLoss of Side Vision □ □□ Diabetes □ □ □Double Vision □ □□ Heart Pain □ □□Dryness □ □□ High Blood Pressure □ □□Mucous Discharge □ □ □Vascular Disease □ □ □Redness □ □ □Sandy or Gritty Feeling □ □□ GASTROINTESTINALItching □ □ □ Diarrhea □ □ □Burning □ □ □ Constipation □ □ □Foreign Body Sensation □ □ □Excess Tearing/Watering □ □□ GENITOURINARYGlare/Light Sensitivity □ □ □ Genitals/Kidney/Bladder □ □ □Eye Pain or Soreness □ □ □Chronic Infection of Eye or Lid □ □□ BONES / JOINTS / MUSCLESSties or Chalazion □ □ □Rheumatoid Arthritis □ □ □Flashes/Floaters in Vision □ □□ Muscle Pain □ □□Tired Eyes □ □ □ Joint Pain □ □ □ENDOCRINELYMPHATIC / HEMATOLOGICThyroid/Other Glands □ □ □ Anemia □ □ □Bleeding Problems □ □ □PSYCHIATRIC □ □□ALLERGIC / IMMUNOLOGIC □ □ □If you have answered “YES” to any of the above or have a condition not listed, please explain & list medications:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
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