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19441 Golf Vista Plaza, Suite 320 Lansdowne, VA 20176 Tel (703) 858-9800 Fax (703) 858-9801 Medical History Questionnaire Name Date Date of Birth___________________Date of last eye exam________________ by_____________________ What is the reason for your visit today? ______________________________________________________ Who is your primary medical doctor? _________________________________________ Do you currently have any problems with your eyes? Loss of vision Redness Eye pain or soreness Blurred vision Sandy or Gritty feeling Infection of the eye or lid (blepharitis) Fluctuating vision Itching Tired eyes Distorted vision (halos) Burning Drooping eyelid Loss of side /peripheral vision Foreign Body Sensation Floaters Double Vision Excess tearing/watering Flashes Dryness Glare/light sensitivity None Mucous discharge Other:______________________________________________________________________________ Glasses Contacts Please check any chronic conditions related to your eyes: Cataracts Glaucoma Detached retina Blindness Lazy eye Eye injury/trauma Corneal problems Macular Degeneration Other; ________________________________ None Please check any eye surgeries you have had: LASIK Blepharoplasty PRK Retinal surgery;_________________________________ Cataract Surgery, left eye Other; _________________________________________ Cataract Surgery, right eye None Please check any conditions you have experienced in the last 6-12 months: Fevers Chills Warm, red, swollen joints Unintentional weight loss/poor appetite Skin rashes/problems Weight Gain Numbness or tingling Fatigue Low back pain worsening with inactivity Headache Anxiety Ear problems (hearing, ringing, painful earlobes) Depression Chronic Cough Diabetes; Type_____; A1C___________BSA___________ Sinus Problems – Chronic or Seasonal Hypothyroidism Hyperthyroidism High Blood Pressure Cancer; Type___________________________________ Chest Pain Night Sweats Irregular heartbeat Lip cold sores/fever blisters Shortness of breath Painful sores inside mouth Heart disease Genital Sores Stomach pain Males – Testicular pain Diarrhea White patches on skin or premature loss/whitening of hair Constipation Upper respiratory infection (sinus, cold) requiring antibiotics Blood in the stool Tick bite with rash at site of bite Joint pain None For women, are you pregnant? Are you nursing? Other Medical Condition(s):____________________________________________________________________ ___________________________________________________________________________________ List any medical surgeries you have had:_________________________________________________________ ___________________________________________________________________________________________ PATIENT MEDICATION LIST I give consent for my medications to be imported from pharmacies. Medication Name Dose Frequency Eye Drops Name Dose Frequency Do you have any allergies to any medications? If yes, please list the medications:____________________________________________________________________ SOCIAL HISTORY Do you dri Do you have visual difficulty when driving? FAMILY HISTORY Disease/Condition Has any member of your immediate family (blood relatives) have/had these diseases? Family Member Lazy Eye Macular Degeneration yes yes no no Mother Father Sister Brother Uncle Aunt Grandmother Grandfather Mother Father Sister Brother Uncle Aunt Grandmother Grandfather Blindness yes no Mother Father Sister Brother Uncle Aunt Grandmother Grandfather Retinal Disorders yes no Mother Father Sister Brother Uncle Aunt Grandmother Grandfather Cataracts yes no Mother Father Sister Brother Uncle Aunt Grandmother Grandfather Glaucoma Diabetes yes yes no no Mother Father Sister Brother Uncle Aunt Grandmother Grandfather Mother Father Sister Brother Uncle Aunt Grandmother Grandfather Heart Disease yes no Mother Father Sister Brother Uncle Aunt Grandmother Grandfather Hypertension yes no Mother Father Sister Brother Uncle Aunt Grandmother Grandfather Stroke yes no Mother Father Sister Brother Uncle Aunt Grandmother Grandfather Thyroid Disease yes no Mother Father Sister Brother Uncle Aunt Grandmother Grandfather Arthritis yes no Mother Father Sister Brother Uncle Aunt Grandmother Grandfather Cancer yes no Mother Father Sister Brother Uncle Aunt Grandmother Grandfather Type:__________________ Patient and/or Guardian’s Signature Date _______________________________________ ________________________________
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