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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:  ______ – _____ – _______



Medication Allergies:   _______________________________              Environmental/Seasonal Allergies: ________________________


Please indicate if you have any of the following conditions:


□  High Blood Pressure

□  High Cholesterol

□  Heart Disease

□  Stroke


□  Dizziness

□  Recent Sickness (flu, cold)

□  Cancer:  please explain:


□  Hearing Loss

□  Sinus Problems


□  Diabetes  If yes, for how many years?  _____

□  Thyroid Disease

□  Kidney Disease


□  Acid Reflux

□  Crohn’s Disease

□  Liver Disease


□  Reiters

□  Prostate Cancer

□  Menopause


□  Clotting Disorder

□  Anemia


□  Herpes Simplex

□  Herpes Zoster (Shingles)

□  Rheumatoid Arthritis

□  Lupus

□  Frequent Cold Sores


□  Rosacea

□  Skin Cancer


□  Headache/Migraine

□  Multiple Sclerosis


□  Depression

□  Attention Deficit Disorder

□  Dementia


□  Asthma


□  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 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).