Medical History Questionnaire Page 2
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1
2Continued, If YES, provide details
YES
NO
DETAILS
NEUROLOGICAL
(MS, stroke, headache,
Migraines, aneurysm, dizziness
PSYCHIATRIC
Anxiety, depression
ENDOCRINE
Diabetes, thyroid
BLOOD/LYMPH
Anemia, cholesterol
ALLERGIC/IMMUNOLOGIC
Rheumatoid arthritis, Reynaud’s, Sjogren’s
FAMILY HISTORY
M=Mother
F=Father S=Sibling GP=Grandparent
DISEASE
YES
NO
RELATIONSHIP TO PATIENT
Blindness
Glaucoma
Macular Degeneration
Cancer
Diabetes
Heart Disease or Hypertension
Kidney Disease
Lupus
Stroke
Thyroid Disease
Arthritis
SOCIAL HISTORY
YES
NO
Live alone, live/w family, nursing home
Living arrangements
Do you drive?
Do you have difficulty driving?
Do you have problems with night vision
If YES, how many hours per day _____
Do you wear contact lenses?
Do you currently wear glasses?
Age of current prescription __________
Do you smoke?
Occasional
½ pk/day
1 pk/day
1+ pk/day
Do you drink alcohol?
Occasional
1/day
2-3/day
4+ /day
Thank you for taking the time to complete this form.
Patient
Physician
Signature:_______________________
Signature: ______________________
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