Low Vision Medical History Questionnaire

Fill Out Your Low Vision Medical History Here

Birthdate

Very important! New patients only:

Who may we thank for referring you to our office? Name of friend or relative:

Or, how else did you choose our office? Another Doctor. Which one?

Or, how else did you learn about us?

Medical History

Do you have any allergies to medications? If yes, what medicines?

List any of the following that you have had: crossed eyes, lazy eyes, glaucoma, retinal disease/macular degeneration, cataracts, eye injury, or eye surgery:

Family History (Disease/Condition):
Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:

Cataract

YesNo?

Crossed Eyes

YesNo?

Glaucoma

YesNo?

Macular Degeneration

YesNo?

Retinal Detachment/Disease

YesNo?

Cancer

YesNo?

Diabetes

YesNo?

Heart Disease

YesNo?

High Blood Pressure

YesNo?

Other:

Review of Systems
Do you currently, or have you ever had any problems in the following areas:

CONSTITUTIONAL

Fever, Weight Loss/Gain

YesNo?

INTEGUMENTARY (Skin)

YesNo?

NEUROLOGICAL

Headaches

YesNo?

Migraines

YesNo?

Seizures

YesNo?

EYES

Dry eyes

YesNo?

Loss of Side Vision

YesNo?

Double Vision

YesNo?

Sandy or Gritty Feeling

YesNo?

Redness

YesNo?

Itching

YesNo?

Burning

YesNo?

Excess Tearing

YesNo?

Chronic Infections of Eye/Lid

YesNo?

Thyroid/Other Glands

YesNo?

ENDOCRINE

Tired Eyes

YesNo?

LYMPHATIC / HEMATOLOGIC

Bleeding Problems

YesNo?

Anemia

YesNo?

ALLERGIC / IMMUNOLOGIC

YesNo?

PSYCHIATRIC

YesNo?

EARS, NOSE, MOUTH, THROAT

Allergies/Hay Fever

YesNo?

Sinus Congestion

YesNo?

Dry Throat/ Mouth

YesNo?

Runny Nose

YesNo?

Chronic Cough

YesNo?

VASCULAR / CARDIOVASCULAR

Emphysema

YesNo?

Asthma

YesNo?

Chronic Bronchitis

YesNo?

RESPIRATORY

Vascular Disease

YesNo?

Diabetes

YesNo?

Heart Condition

YesNo?

High Blood Pressure

YesNo?

GASTROINTESTINAL

Constipation

YesNo?

Diarrhea

YesNo?

BONES / JOINTS / MUSCLES

Venereal Disease

YesNo?

Genital / Kidney / Bladder

YesNo?

GENITOURINARY

Joint Pain

YesNo?

Rheumatoid Arthritis

YesNo?

Muscle Pain

YesNo?

ATTESTATION

Date

* I have read and understand, to the best of my knowledge, the above information. I certify that all statements are truthful and accurate. I authorize the release of any information concerning my (or my child's) health care, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I understand that I am financially responsible for any service considered non-covered, any deductibles and/or co-payments as well as any service denied due to non-participating provider.

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