Medical History Questionnaire Name First Last PhoneEmail Review of Systems: Do you currently have or ever had any problems in the following areas or are being treated for:ConstitutionalYesnoFever, Weight Loss/GainCancerCardiovascularYesnoAnginaHigh Blood PressureOther Ears, Nose, Mouth, ThroatYesnoSinus CongestionDry Throat/MouthChronic CoughOther RespiratoryYesnoAsthmaChronic BronchitisTuberculosisSleep ApneaOther GastrointestinalYesnoDiarrhea/ConstipationGERDOther GenitourinaryYesnoGenitalsKidneysBladderOther Bones/Joints/MusclesYesnoOsteoarthritisOther Dermatological/IntegumentaryYesnoAcneEczemaRosaceaOther PsychiatricYesnoAnxietyDepressionOther NeurologicalYesnoHeadachesMigrainesSeizuresStrokeOther EndocrineYesnoDiabetesThyroidOther Lymphanic/HematologicYesnoAnemiaBleeding ProbblemsHigh CholesterolOther Infectious DiseaseYesnoHepatitisHerpesSyphilisOther Allergic/Immune DiseaseYesnoSeasonal/EnvironmentalDrug AllergyLupusRheumatoid ArthritisSjogren’s SyndromeOther EyesYesnoGlaucomaCataractsMacular DegenerationMacular DegenerationLoss of VisionEye Turn/ “Lazy Eye”Dry EyeEye InjuriesMedical HistoryPregnant Yes No Nursing Yes No List all major injuries, surgeries, and/or hospitalizations you have hadSocial HistoryDo you drive? Yes No do you have any visual difficulty when driving? Yes No Do you use smoke or have you in the past? Yes No FORMER How much? Do you use recreational drugs? Yes No Type/How much? Do you drink alcohol? Yes No Type/How much? Family Historyparents, grandparents, siblings, children: living or deceasedDISEASE/CONDITIONRELATIONSHIP TO YOU Cancer RELATIONSHIP TO YOU Diabetes RELATIONSHIP TO YOU High Blood Pressure RELATIONSHIP TO YOU High Blood Pressure RELATIONSHIP TO YOU Thyroid Disease (high or low) RELATIONSHIP TO YOU Kidney Disease RELATIONSHIP TO YOU Heart Disease RELATIONSHIP TO YOU Stroke RELATIONSHIP TO YOU Glaucoma RELATIONSHIP TO YOU Cataract RELATIONSHIP TO YOU Macular Degeneration RELATIONSHIP TO YOU Retinal Detachment/Disease RELATIONSHIP TO YOU Blindness RELATIONSHIP TO YOU Crossed Eyes RELATIONSHIP TO YOU Amblyopia RELATIONSHIP TO YOU Primary Care Doctor:Name Address PhoneList of MedicationsSignatureDate MM slash DD slash YYYY