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MEDICAL HISTORY QUESTIONNAIRE
NAME:________________________________________________AGE______DA
TE___________________
Date of last eye exam______________Where was this done(name of Dr./Clinic)______________________
Medications(prescription,over the counter,vitamins,homeopathic):________________________________
__________________________________________________________________________________________
Are you currently on, or have you ever taken Flomax, Hytrin, Cardura, Uroxatral or Sawpalmetto?

_________________________________________________________________________________________
Allergies to medications:____________________________________________________________________
List all major illnesses, injuries, surgeries:_____________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Have you ever had trauma to one or both eyes?______________________________________________
Do you currently have any problems in the following areas? If "YES" please provide information.

EYES(glaucoma,cataract,retinal disease,etc.)
ENDOCRINE/DIABETES (thyroid,etc.)
GENERAL(fever,weight loss,fatigue,cancer)
EARS,NOSE,THROAT(dry mouth,sinus,etc.)
CARDIOVASCULAR(heart,high blood pressure)
RESPIRATORY(asthma,emphysema,etc.)
GENITAL, KIDNEY, BLADDER
MUSCLES, BONES, JOINTS
(arthritis, etc.)
SKIN(acne,skin cancer,rashes,etc.)
NEUROLOGICAL(multiple sclerosis,stroke)
PSYCHIATRIC(anxiety,depression,schizophrenia)
GASTROINTESTINAL(intestinal or stomach)
BLOOD/LYMPH(high cholesterol,anemia)
ALLERGIC/IMMUNOLOGIC
FAMILY HISTORY
M=Mother F=Father S=Sibling GP=Grandparent
Blindness
Glaucoma
Macular Degeneration
Diabetes
Other eye disease

SOCIAL HISTORY
Do you drive?.
Do you have visual difficulty with driving?.
Do you have visual difficulty with reading?.
Have you ever tried contact lenses?.
Do you currently wear contacts?.
Do you wear glasses?.
Do you smoke?.

Do you have diabetes?.
History reviewed □ No changes □ Additions as noted above
Patient's Signature_________________________________________Date_____________________
Physician's Signature_______________________________________Date_____________________
400 Indiana St, Suite 360 Golden, CO 80401 (303) 384-3700 Fax: (303) 384-3855 MEDICAL HISTORY QUESTIONNAIRE
_______ AGE:________ DATE:_______________
Date of last eye exam______________Where was this done(name of Dr./Clinic)______________________
Medications(prescription,over the counter,vitamins,homeopathic):________________________________
__________________________________________________________________________________________
Are you currently on, or have you ever taken Flomax, Hytrin, Cardura, Uroxatral or Sawpalmetto?

_________________________________________________________________________________________
Allergies to medications:____________________________________________________________________
List all major illnesses, injuries, surgeries:_____________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Have you ever had trauma to one or both eyes?______________________________________________
Do you currently have any problems in the following areas? If "YES" please provide information.

Explanation of problem
M=Mother F=Father S=Sibling GP=Grandparent
Relationship to Patient
If yes,what is your contact lens prescription?
If yes,how old are your current glasses?
If yes: occasional 1/2 pack/day 1 pack/day
2 pack/day 3+ pack/day

History reviewed □ No changes □ Additions as noted above
Patient's Signature_________________________________________Date_____________________
Physician's Signature_______________________________________Date_____________________
400 Indiana St, Suite 360 Golden, CO 80401 (303) 384-3700 Fax: (303) 384-3855

Source: http://www.rmocolorado.com/UserFiles/file/medical-history-questionairre-01-07-sheet1.pdf

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