Medical History Questionnaire

Today's Date

Patient Name (Required)

First Name

Last Name

Vision History

Are you having difficulties with your vision? (Required)

YesNo

Do you wear glasses? (Required)

YesNo

When do you wear glasses?

If other, specify prescription

How many hours do you spend on the computer and/or any smart screen device? (Required)

Do you wear contact lenses?(Required)

YesNo

How long have you been wearing your current pair of contacts?

Personal Medical History

List any medications that you take (including over the counter meds, oral contraceptives, aspirin and home remedies) or type N/A (Required)

Do you have any allergies to medications? (Required)

YesNo

Please list all major injuries, surgeries and/or hospitalizations you have had

Are you pregnant or nursing? (Required)

YesNoNot Applicable

Please note any general medical history for the following conditions

Respiratory problems (shortness of breath, cough) (Required)

YesNo

Chronic fatigue, fever, unexpected weight gain/loss (Required)

YesNo

Ear, nose or throat problems (Required)

YesNo

Skin conditions (rashes, dryness) (Required)

YesNo

Musculoskeletal problems (arthritis, muscle pain) (Required)

YesNo

Heart problems (disease, blood pressure, irregular beat) (Required)

YesNo

Cancer (Required)

YesNo

Diabetes (Required)

YesNo

High Cholesterol (Required)

YesNo

Kidney Disease (Required)

YesNo

Liver Disease (Required)

YesNo

Thyroid Disease (Required)

YesNo

Neurologic problems (numbness, paralysis, headache) (Required)

YesNo

Psychiatric problems (depression, anxiety) (Required)

YesNo

Gastrointestinal (diarrhea, constipation, etc.)

YesNo

Genitourinary (genitals, kidneys, etc.)

YesNo

Lymphatic/ Hematological and Endocrine (Thyroid / other glands)

YesNo

Please list all other conditions we should note. If none, please include N/A

Are there any medical or eye diseases that run in the family ( heart disease, diabetes, cancer, glaucoma, macular degeneration)? If none, please include N/A.

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