Medical History Questionnaire

Subset 1

Name

Nick Name

Date of Birth

Ethnicity

HispanicNot Hispanic

Race

American Indian or Alaska NativeAsianAfrican AmericanNative hawaiian or Other Pacific IslanderWhite

Allergies

MildModerateSevere

Past Ocular History (Please mark all that apply)

CataractsDiabetic Retinopathy Dry EyesGlaucomaHyperopia (Far sighted)IritisKeratoconusMacular DegenerationOptic NeuritisMyopia (Near sighted)Retinal DetachmentAmblyopia (Lazy eye)AphakiaAstigmatism

Ocular Surgeries

Foreign Body Removal

Blepharoplasty

Strabismus Surgery

Punctal Plugs

Retinal Laser Surgery

Vitrectomy

Laser

Corneal Transplant

Cataract Surgery

LASIK

PRK (eye muscle surgery)

Other

Current Eye Medications: Please List

Other Medical History

Thyroid DiseaseCongestive Heart FailureHeadacheLung DiseaseAnemiaCOPDHigh Blood PressureLupusArthritisDiabetes Type1High CholesterolMigraineArrhythmiaDiabetes Type2HIV/AIDSPolymyalgiaAsthmaEczemaKidney DiseasePsychiatric DisorderBleeding DisorderFibromyalgiaKidney StonesSkinCancerCancerHearing LossLiver DiseaseStrokeChicken PoxHerpesZoster/ShinglesMeningitisToxoplasmosisHepatitisA/B/CHistoplasmosisMRSAWound InfectionHerpes SimplexSyphillis

General Surgeries/Operations (Please List)

All Other Medications (Please List)

Review of Systems (Check all that Apply)

Eyes

Previous SurgeryContact LensPainDouble VisionGlaucomaCataractsMacular DegenerationDry EyesFlashesFloaters

Respiratory

CoughCongestionWheezingAsthma

Gastrointestinal

HeartburnNausea / VomitingJaundice / Hepatitus

Blood / Lymphnodes

Easy BruisingGums Bleed EasyProlonged BleedingHeavy Aspirin Use

MusculoSkeletal