Fill Out Your Low Vision Medical History Here Low Vision Medical History Questionnaire Today's Date MM slash DD slash YYYY Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell PhoneWork PhoneEmail Medical InsuranceSocial Security #Occupation (or Grade):Birth Date MM slash DD slash YYYY Age: 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 Insurance List Saw Sign/Building Internet Or Other?Medical HistoryDo you have any allergies to medications? If yes, what medicines?Please list all medication(s) that you are currently taking: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 Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions: DISEASE/CONDITIONCataract Yes No ? Crossed Eyes Yes No ? Glaucoma Yes No ? Macular Degeneration Yes No ? Retinal Detachment/Disease Yes No ? Cancer Yes No ? Diabetes Yes No ? Heart Disease Yes No ? High Blood Pressure Yes No ? Other:Review of Systems: Do you currently, or have you ever had any problems in the following areas:CONSTITUTIONALFever, Weight Loss/Gain Yes No ? INTEGUMENTARY (Skin) Yes No ? NEUROLOGICALHeadaches Yes No ? Migraines Yes No ? Seizures Yes No ? EYESDry eyes Yes No ? Loss of Side Vision Yes No ? Double Vision Yes No ? Redness Yes No ? Sandy or Gritty Feeling Yes No ? Itching Yes No ? Burning Yes No ? Excess Tearing Yes No ? Chronic Infections of Eye/Lid Yes No ? Thyroid/Other Glands Yes No ? ENDOCRINETired Eyes Yes No ? LYMPHATIC / HEMATOLOGICBleeding Problems Yes No ? Anemia Yes No ? ALLERGIC / IMMUNOLOGIC Yes No ? PSYCHIATRIC Yes No ? EARS, NOSE, MOUTH, THROATAllergies/Hay Fever Yes No ? Sinus Congestion Yes No ? Dry Throat/ Mouth Yes No ? Runny Nose Yes No ? Chronic Cough Yes No ? VASCULAR / CARDIOVASCULAREmphysema Yes No ? Asthma Yes No ? Chronic Bronchitis Yes No ? RESPIRATORYVascular Disease Yes No ? Diabetes Yes No ? Heart Condition Yes No ? High Blood Pressure Yes No ? GASTROINTESTINALConstipation Yes No ? Diarrhea Yes No ? BONES / JOINTS / MUSCLESVenereal Disease Yes No ? Genital / Kidney / Bladder Yes No ? GENITOURINARYJoint Pain Yes No ? Rheumatoid Arthritis Yes No ? Muscle Pain Yes No ? ATTESTATION 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 providerPatient or Parent or Guardian SignatureDate MM slash DD slash YYYY Δ
