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Medical History Questionnaire

 

Today’s Date: ______/_______/_______

 

 

Patient’s Last Name: __________________________________ First Name: ____________________________ MI: ______

 

Address (mailing): _____________________________________  City: _________________State: _____ ZIP: ___________

 

Phone: (H)­­­­__________________ (W) __________________ (Cell) __________________    Birth Date: ____/_____/_____

 

E-mail: __________________________________   Occupation: ________________ Employer: _______________________

 

Responsible Party’s Last Name:  _________________________________   First Name: ___________________ MI: ______

 

Insurance: _________________ Group and ID No.: _______________________________  SSN:  ______ – _____ – _______

 

Allergy

Medication Allergies:   _______________________________              Environmental/Seasonal Allergies: ________________________

 

Please indicate if you have any of the following conditions:


Cardiovascular                   

□  High Blood Pressure

□  High Cholesterol

□  Heart Disease

□  Stroke

Constitutional/General

□  Dizziness

□  Recent Sickness (flu, cold)

□  Cancer:  please explain:

 

Cranial/Facial

□  Hearing Loss

□  Sinus Problems

 

Endocrine

□  Diabetes  If yes, for how many years?  _____

□  Thyroid Disease

□  Kidney Disease

 

Gastrointestinal

□  Acid Reflux

□  Crohn’s Disease

□  Liver Disease

 

Genitourinary

□  Reiters

□  Prostate Cancer

□  Menopause

 

Hematologic/Lymphatic

□  Clotting Disorder

□  Anemia

 

Immunologic:

□  Herpes Simplex

□  Herpes Zoster (Shingles)

□  Rheumatoid Arthritis

□  Lupus

□  Frequent Cold Sores

 

Integumentary/Skin:

□  Rosacea

□  Skin Cancer

 

Neurologic

□  Headache/Migraine

□  Multiple Sclerosis

 

Psychiatric

□  Depression

□  Attention Deficit Disorder

□  Dementia

 

Respiratory:

□  Asthma

□  COPD

□  Bronchitis
Please list other health conditions not mentioned above:  ______________________________________________________

___________________________________________________________________________________________________

Please list your primary care provider:  _____________________________________________________________________

Due to government regulations, we are now required to ask your:   Height:  _______________   Weight:  _______________

 

Please see other side.

 

 

 

 

Please list medications you are taking:______________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

□ I use cigarettes/tobacco regularly.                   □  I use alcohol regularly.                     □   I use other substances.

 

Family Medical History:

Please indicate if anyone in your family has:                       Please indicate if on your maternal or paternal side.

□  Diabetes                                                      Relation:    _________________________________________________

□  High Blood Pressure                                 Relation:    _________________________________________________

□  Heart Disease                                             Relation:    _________________________________________________

□  Cancer                                                         Relation:    _________________________________________________

□  Other                                                           Relation:    _________________________________________________

 

Personal Eye History:

 

  I have had an eye operation.   Which Eye?  ____________    Type:  _______________________  Date:  _________

□  I have had an eye injury.        Which Eye?  ____________    Type:  _______________________  Date:  _________

□  I have glaucoma.                     □  I have cataracts.            □  I have macular degeneration.          □  I have dry eyes.

□  I have other eye problems:  __________________________________________________________________________

 

Family Eye History:

Please indicate if anyone in your family has:                          Please indicate if on your maternal or paternal side.

□  Glaucoma                                                     Relation:    ________________________________________________

□  Macular Degeneration                               Relation:    ________________________________________________

 

Lifestyle Questionnaire:

□  I wear glasses.                                                                               □  I wear contacts.

□  I do not wear contacts, but am interested in them.                  □  I am interested in new eyeglass frames.

□  I am interested in prescription sunglasses.                                               □  I am interested in laser eye surgery.

 

Do you have trouble with:

□  Glare while driving at night          □  Light sensitivity           □  Eyestrain while working on the computer

□  Headaches resulting from eyestrain                                           □  Double vision

 

To help us get to know you better and to better understand your visual needs, please indicate what hobbies/activities you are interested in:   _________________________________      __________________________________________________

_____________________________________________      __________________________________________________

 

 

Whom may we thank for referring you?  _____________________________________________________________________

 

 

 

Please sign below, indicating that (1) you have had the opportunity to read our

Notice of Privacy Practices,(2) authorizing the release of medical or other information necessary to process your insurance claim, and (3) authorizing insurance benefits to be paid directly to

SheridanEyecareCenter (you will be responsible for non-covered services).

 

 

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