Download Health Questionnaire Name: Date: Email: SS #: Pharmacy: What is

Health Questionnaire
Name:_________________________
Email:_____________________
Date:__________________________
SS #:______________________
Pharmacy:_____________________
What is today’s reason for your visit?_______________________________________________
Please check all that apply.
Ethnicity: Hispanic or Latino
Latino
□ Not Hispanic or
□
□
Alaska Native□ Asian□ Black or African American□
Native Hawaiian or Pacific Islander□ White□ Other
Race□
Race: America Indian
□ Spanish□ French□
Japanese□ Italian Russian□ Portuguese□ Polish□
Mandarin□ Chinese□ Korean□ Hmong□ Vietnamese□
Laotian□
Preferred Language: English
Do you have any problems with any of the following? Please check all that apply.
□ Floaters□ Tearing□ Mattering□
Headache□ Photophobia□ Loss of Sharpness□ Loss of
Vision□ Itching□ Pain□ Diplopia□ Red Burning□
Quality: Bothersome□ Painful□ Awareness
Severity: Mild□ Moderate□ Severe□
Duration: Hours□ Days□ Months□ Weeks□ Years□
Ocular: Flashes
Timing: New Condition□ Return of Previous
□ Ongoing□
Context: Surgery□ Injury□ Infection□ Medical
Condition□
Condition
Modifying Factors: Treated by another provider
taking medications
N/A
□
□ taking drops□
□
Do you have any problems with any of the following? Please check all that apply.
Constitution (General Health): Developmental
□ Fatigue□ Syndrome□ Cancer□
Ear, Nose, Throat: Hearing Loss□ Dry mouth□
Sinusitis□ Laryngitis□
Neurological: Stroke/CVA□ Tumor□ Migraine□
Multiple Sclerosis□ Cerebral Palsy□ Epilepsy□
Psychological: Depression□ Attention Deficit□
Anxiety□ Bipolar□
Cardiovascular: Negative□ Hypertension□
Stroke/CVA□ Heart Disease□ Vascular□ Congestive
Heart Failure□
Respiratory: Bronchitis□ Emphysema□ Asthma□
Sleep Apnea□ Smoker□ Obstruction□
Gastrointestinal: Acid Reflux□ Ulcer□ Colitis□
Crohn’s□ Celiac Disease□
Disabilities
□ Pregnant□ Chlamydia□
Herpes□ Kidney Disease□ Prostate/Cancer□ STDBPH□
Musculoskeletal: Ankylosing Spondylitis□
Fibromyalgia□ Gout□ Osteoporosis□ Muscular
Dystrophy□ Arthritis□
Integument (Skin): Eczema□ Herpes Simplex/Cold
Soresv Rosacea□ Psoriasis□
Endocrine(Hormone): Type 2 Diabetes□ Mellitus□
Thyroid□ Type 1 Diabetes□ Hormone Dysfunction□
Blood/ Lymphatic: Hypercholesteremia□ Ulcer□
Anemia□ Large Volume Blood Loss□
Allergic/ Immunologic: Rheumatoid Arthritis□
Lupus□ Drug Allergies□ Environmental Allergies□
Sjogrens Syndroe□ N/A□
Genitourinary: Nursing
List the medications, supplements and what you are taking them for:
Medication:
Reason:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Do you have any allergies to any medications? Please list:
___________________________________________________________________
Do you have any seasonal allergies? Please list:
___________________________________________________________________
If any alcohol use? Amount Daily
□ Weekly□ Monthly□ __________________
If any current tobacco use? How many daily__________
Please check all that apply.
□ Cigars□
Previous Smoker? Y□ N□
Cigarettes
Pipes
□ Smokeless□
Employer:_____________________________
Occupation: ____________________________
Student/Grade: __________________________
Have your eyes had any problems with any of the following? Please check all that apply.
□ Dry eye□ Injury□
Keratoconus□ Retinal Detachment□ Glaucoma□
Cataract□ Age Related Macular□
Ocular: Nystagmus
□ Surgery□ Retinal Hole□ Retinal
Degeneration□ Amblyopia□ Strabismus□
Inflammatory Disorder□ Patching□ N/A□
Degeneration
Do any significant diseases run in your family? Please check all that apply.
Cancer
□ Thyroid□
Diabetes
□ High Blood Pressure□ N/A□
Do any significant eye diseases run in the family? Please check all that apply.
□ Cataracts□ Macular Degeneration□
Retinal Hole□ Amblyopia□ Strabismus□
Glaucoma
Are you interested in contacts? Y
Patching
N/A
□ Myopia□ Nystagmus□ Inflammatory□
□
□ N□
Do you have any of the following symptoms? Please check all that apply.
□ Light sensitivity□ Eyes blur when tired□
Hurt when reading□
Dry eye
Do you have prescription sunglasses? Y
□ N□
□ Hurting while outdoors□
Hurt when driving□ N/A□
Blur with computer use