MEDICAL HISTORY QUESTIONNAIRE       NAME: Today’s Date: 02/06/2012 Last Eye Exam: Last Physical/Medical Exam: Name of Primary Medical Doctor: Phone:   Do you have any allergies to medications? NO  YES If yes, explain: List any medications you take ( include oral contraceptives, aspirin, over the counter medications and home remedies): 1. 2. 3. 4. 5. 6.   List all major injuries, surgeries and/or hospitalizations you have had: Are you pregnant and/or nursing? NO YES   EYES: Do you wear glasses ?  NO YES If yes, how old are your lenses ? Do you wear contact lenses ? NO YES If yes, how old are your lenses ? Type of contact lenses ? Rigid Soft Daily Wear Extended Wear Other What solutions do you use to clean your contact lenses ? What eyedrops do you use? How often?          Are your contact lenses comfortable? NO YES     Are you interested in color contact lenses? NO YES     Have you had any eye infection and/or eye surgeries: NO YES Explain: Are you interested in Laser Surgery Correction? NO YES       Do you currently, or have you ever had any problems in the following areas: Loss of Vision  NO YES Dryness  NO YES Blurred Vision  NO YES Redness NO YES Distorted Vision / Haloes NO YES Itching NO YES Loss of Side Vision NO YES Burning NO YES Double Vision  NO YES Sandy or Gritty NO YES Tired Eyes NO YES Foreign Body Sense NO YES Glare / Light Sensitivity NO YES Excess Tear / Water NO YES Eye Pain or Soreness NO YES Mucous Discharge NO YES Flashes / Floaters in vision NO YES Sties or Chalazion NO YES Crossed/Lazy Eye NO YES Chronic Infection of EyeLid NO YES Glaucoma  NO YES Cataract NO YES Drooping Eyelid NO YES Retinal Disease NO YES   This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer: Check here if you do: Do you drive? NO YES     If yes, do you have visual difficulty when driving? 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 use illegal drugs? NO YES If yes, type/amount/ how long: Have you been exposed to or infected with: HIV      Hepatitis     Syphillis     Herpes Please, check any medical condition you have: Fever,Weight Loss/Gain NO YES Allergies/Hay Fever NO YES Headaches NO YES Sinus Congestion  NO YES Migraines NO YES Dry Throat/Mouth NO YES Seizures NO YES Post Nasal Drip NO YES Rheumatoid Arthritis NO YES Asthma NO YES Muscle Pain  NO YES Chronic Bronchitis NO YES Joint Pain NO YES Emphysema NO YES Diabetes NO YES Diarrhea NO YES High Blood Pressure  NO YES Constipation NO YES Heart disease NO YES Kidney/Bladder NO YES Vascular Diseases  NO YES Anemia  NO YES Thyroid Gland NO YES Bleeding problems NO YES Cancer  NO YES If yes, explain: Other; Please, explain & list medications: Please, note any family history ( parents, grandparents, siblings, children; living or deceased ) for the following conditions: Blindness NO YES Relation to you Diabetes NO YES Glaucoma  NO YES Relation to you Hypertension NO YES Macula Degen NO YES Relation to you Heart Disease NO YES Retinal Detach NO YES Relation to you Cancer NO YES Crossed Eyes NO YES Relation to you Lupus NO YES Thyroid Dis NO YES Relation to you Multiple Scleros NO YES Other:

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