PATIENT HISTORY QUESTIONNAIRE. Please complete the following. If you have any in your family (e.g., diabetes, high blood pressure, glaucoma, macular degeneration) …
PATIENT HISTORY QUESTIONNAIRE
Please complete the following If you have any questions, we would be happy
to assist you
First Name ____________________________ MI ______ Last Name
__________________________________
Address ________________________________ City ___________________ State
______ Zip _____________
Telephone H _____________________ Day _____________________Email
_________________________
Insured Partys: Name _____________________ Date of Birth ____________ Ins
ID No _________________
Your
Employer____________________________________________Occupation______________
__________
Emergency contact telephone number
_________________________________________________________
Date of last eye exam ________________ Were you dilated? _________________
Todays date ____________
Referred by ____________________________ Name of Primary Care Physician
_________________________
MEDICAL INFORMATION
What is your general health?
__________________________________________________________________
Do you have problems with any of these systems?
Eyes
Y/N
Gastrointestinal Y/N Nervous Y/N Mental
Y/N
Ears/Nose/Throat Y/N Genitourinary Y/N Endocrine glands
Y/N
Cardiovascular Y/N Musculoskeletal Y/N Blood/lymph
Y/N
Respiratory Y/N Integumentary skin Y/N
Allergic/immunologic Y/N
Please explain
____________________________________________________________________________
__
Diabetes ? Y/N Type ___________ Date of Diagnosis__________ HIV? Y/N
Date of Diagnosis__________
Allergies? Y/N Allergic to what? _______________________________ What
happens? _________________
Medication allergy? Y/N What happens?
________________________________________ Headaches? Y/N
Other health problems
________________________________________________________________________
Current medications
________________________________________________________________________
Have you had any operations? Y/N Kind? __________________________________
When? _______________
Name of family/primary care doctor ______________________________ Date of
last visit _________________
Date of last tetanus shot
_______________________________________________________________________
FAMILY/SOCIAL HISTORY
Do any medical or eye diseases run in your family eg, diabetes, high
blood pressure, glaucoma, macular degeneration?
Yes No If yes, please explain:
____________________________________________________________
Do you use tobacco products? ______ How much?________ Do you drink
alcohol?____ How much?________
PERSONAL EYE INFORMATION
Reason for todays visit
______________________________________________________________________
Do you wear glasses? Y/N Do you wear contact lenses Y/N Do you have
reading problems? Y/N
Are you currently experiencing any eye symptoms? Please check all that
apply:
Eye Pain Blurred Vision Eyelid Crusting Flashes of Light
Halos
Discharge Light Sensitivity Double Vision Decreased Vision
Floaters
Have you ever had an eye injury? Please describe
_________________________________________________
Have you ever had eye surgery? Please list type, which eye, and approximate
dates
________________________________ R/L ________________________________
________________________________ R/L ________________________________
Have you ever been diagnosed with an eye disease? Please list condition,
which eye, date diagnosed
_____________________________ R/L ______________________________ Currently
being treated? Y/N
_____________________________ R/L ______________________________ Currently
being treated? Y/N
Are you currently using any eye medications? Please list name and how often
used: _______________________
____________________________________________________________________________
______________
Please check any of the following that you would like more information
about: Glaucoma Cataract Dry Eye
Macular Degeneration Diabetic Eye Disease Floaters Flashes
Refractive Surgery Contact Lenses
_________________________________________________
__________________________________
Patient Signature Date
Doctors Initials Date
9/07
Source:valleyeyecarecenter.com
