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MEDICAL HEALTH QUESTIONAIRE
SCHONHOFEN OPTOMETRY, PA
Name:
Date of Birth:
Primary Physician:
Last Physical Exam:
Height:
Weight:
REVIEW OF SYSTEMS: Please circle any of the following that pertain to you
Eyes:
Glaucoma
Cataract
Macular Degen
Blurry Vision
Flashes
Floaters
Dryness
Watery Eyes
Infections
Other
Cardiovascular:
Aneurysm
Heart Disease
High Blood Pressure
Stroke
Elevated Cholesterol
Phlebitis
Other
Blood/Lymphatic:
Anemia
Bleeding Problems
Leukemia
Breast Cancer
Other
Musculoskeletal:
Arthritis
Muscle/Joint Pain
Muscle Spasms
Muscle Weakness
Joint Swelling
Integumentary(Skin):
Eczema
Dermatitis
Rosacea
Acne
Psoriasis
Cysts
Warts
Melanoma
Skin Cancer
Other
Allergic/Immunologic:
Allergies
Rheumatoid Arthritis
Lupus
Autoimmune Disease
Other
Endocrine:
Diabetes Type 1/Type 2
Hormonal Dysfunction
Cholesterol/Lipid Problems
Thyroid Dysfunction: Hyper/Hypo
Cancer
Other
Respiratory:
Emphysema
Pneumonia
Asthma
Bronchitis
Cancer
Other
Constitutional:
Developmental Disability
Unintended Weight Loss
Trauma
Chronic Fatigue
Other
Gastrointestinal:
Diarrhea
Constipation
Vomiting
Heartburn
Ulcers
Cancer
Other
Ears/Nose/Throat:
Hayfever
Sinus Congestion
Dry Mouth
Dry Throat
Cancer
Other
Nervous System:
Seizures
Multiple Sclerosis
Headaches/Migraines
Paralysis
Numbness
Other
Genitourinary:
Ovarian Cancer
Vaginal Disorder
Uterine Cancer
Prostate Cancer
Prostate Disorder
Kidney Disorder
Bladder Disorder
Other
Mental:
Sleep Disorder
Depression
Anxiety Disorder
Mood Changes
Bipolar Disorder
Other
SOCIAL HISTORY: Please circle and answer the following questions.
Do you use tobacco products? Yes No Cigarettes/Cigars/ Snuff/ Chew How Long?__
Do you drink alcohol?
No
Do you use addictive agents?
Social (1-2 drinks daily)
Yes No
What?
Have you been infected with: Gonorrhea Syphilis HIV
Have you had a blood transfusion?
More than 2 drinks daily
Frequency
Hepatitis None
Yes No
MEDICATION HISTORY: Please include prescriptions, oral contraceptives, supplements, over the counter,
analgesics (acetaminophen, aspirin, etc).
MEDICATION ALLERGIES: Please list all known medication allergies.
PAST HISTORY: Please list and date any of the following that you answer “yes”.
Have you been injured? Yes No
Have you had surgery? Yes No
Are you currently pregnant? Yes No
(Due Date:
)
FAMILY HISTORY: Please mark the following conditions that apply to your parents, grandparents, brothers,
sisters, or children.
Blindness
Cataract
Crossed eyes
Glaucoma
Macular Degeneration
PATIENT SIGNATURE:
Retinal Detachment
Retinal Disease
Melanoma (eye or otherwise)
Cancer
Diabetes
TODAY’S DATE:
Heart Disease
High Blood Pressure
Elevated Cholesterol
Kidney Disease
Migraine
INITIAL IF NO CHANGE