Patients History Questionnaire
Patient History Questionnaire
Patient Info
Patient Name
*
Patient Name
First
First
Last
Last
Date of Birth
Today’s Date
Occupation
Employer
Emergency Contact Name
Phone Number
Medical Information
What is your general Health?
Do you have any problems with the following systems?
Gastrointestinal
–
yes
no
Nervous
–
yes
no
Endocrine (glands)
–
yes
no
Ears/Nose/Throat
–
yes
no
Urinary
–
yes
no
Blood/Lymph
–
yes
no
Cardiovascular
–
yes
no
Muscles/Bones
–
yes
no
Allergic/Immunologic
–
yes
no
Respiratory
–
yes
no
Integumentary (skin)
–
yes
no
Headaches
–
yes
no
High Blood Pressure
–
yes
no
Eyes
–
yes
no
Mental
–
yes
no
Please Explain
Diabetes
–
yes
no
Type
Date of diagnosis
Allergies to Medication
–
yes
no
Which?
Reactions?
Other health problems
Current medication(s)
–
Have you had any operations?
–
yes
no
Kind?
When?
Name of family doctor
Date of last visit
Date of last tetanus shot
Family History
High Blood Pressure
–
yes
no
Macular degeneration
–
yes
no
Diabetes
–
yes
no
Retinal detachment
–
yes
no
Glaucoma
–
yes
no
Cataracts
–
yes
no
Relation
Personal Eye Information
Do you have any eye conditions or problems?
–
yes
no
What kind?
Have you had any eye operations?
–
yes
no
Type
Date
Have you had any eye injury?
–
yes
no
Cataracts?
Dry eyes?
Macular degeneration
–
yes
no
Retinal detachment?
–
yes
no
Blurred vision?
–
yes
no
Do you wear glasses?
–
yes
no
Contact lenses?
–
yes
no
Type
Additional information
Social History
Do you use tobacco products?
–
yes
no
If yes, type/amount/how long:
Do you drink alcohol?
–
yes
no
If yes, type/amount/how long:
Do you use illegal drugs?
–
yes
no
If yes, type/amount/how long:
Have you ever been exposed to or infected with an STD:
–
yes
no
Gonorrhea
–
yes
no
Hepatitis
–
yes
no
HIV
–
yes
no
Syphilis
–
yes
no
Submit