Medical History Questionaire Template Page 2
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2FAMILY OCULAR HISTORY:
Has anyone in your immediate family ever been diagnosed with any of the following OCULAR conditions? Please check all that apply and
select that person with the closest relation to you. [e.g. mother, father, brother, sister, grandfather, grandmother, uncle or aunt.]
Amblyopia (Lazy Eye):
Diabetic Retinopathy:
Retinal Detach/Disease:
Blindness:
Glaucoma:
Strabismus (Crossed Eye):
Other Ocular Disease:
Cataracts:
Macular Degeneration:
FAMILY MEDICAL HISTORY:
Has anyone in your immediate family ever been diagnosed with any of the following MEDICAL conditions? Please check all that apply and
select that person with the closest relation to you. [e.g. mother, father, brother, sister, grandfather, grandmother, uncle or aunt.]
Hypertension:
Heart Disease:
Cancer:
High Cholesterol:
Thyroid Disease:
CVA (Stroke):
Diabetes Mellitus:
MEDICATIONS:
Are you taking any PRESCRIPTION or OTC medications?
Yes
No
If YES, please list (or provide a copy of) those meds.
If YES, please list those medications.
Are you allergic to any medications?
Yes
No
SOCIAL HISTORY:
TOBACCO USE - Please select that option which most closely represents your personal use of tobacco.
Never Smoked
Current Smokeless Tobacco User
Former Smoker
Stopped Smoking:
Current Everyday Smoker
Packs per Day:
Years Smoking:
Current Someday Smoker
Packs per Day:
Years Smoking:
ALCOHOL USE - Please select that option which most closely represents your personal use of alcohol.
None
Social Use Only
1-2 Drinks Daily
Above Average Use
Alcohol Dependence
How did you hear about our office?
Referral - Family or Friend
Established Patient
Website / Online
Referral - Family Doctor
Yellow Pages/Phone Book
Walk-in
Insurance Company
Name of person we can thank:
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Parent category: Medical