miyasakaeyecare.com - Medical History Questionnaire

Medical History Questionnaire
Today's Date

MonthDayYear
Date
Name

First NameMILast Name
Date of birth

MonthDayYear
Date
Patient Ocular History
Blurred visionEyestrainDouble visionBlindnessDry eyesTeary eyesRed eyesItchy eyesFlashesFloatersEye pain/irritationRetinal diseaseCataractsAmblyopia (lazy eye)Strabismus (eye turn)GlaucomaDischarge from eyesLoss of visionMacular degenerationEye injury
Eye surgery (type and date)
Other
Eye surgery (type and date)
Doctor's name
YesNo
YesNo
Hard/Gas PermeableSoftMultifocal
Cleaning Solution
Right eye
Brand
Power
Base Curve (BC)
Left eye
Brand
Power
Base Curve (BC)
YesNo
Patient Medical History
High blood pressureHeadachesHigh cholesterolHeart diseaseRheumatoid diseaseThyroid diseaseDiabetesCancer
Date diagnosed last HA1c & when?
Type
Surgeries (type and date)
Other
Medications
Please list the name, dosage, and frequency for all medications currently taken, including eye drops,supplements and OTC medications.
Allergies
YesNo
If yes, please list all food, drug, and any other allergies you may have.
Review of Systems

Do you currently or have you recently had any of the following conditions?

Rows	Yes	No	If yes, please explain
Constitution (e.g. chronic fever, recent weight loss or gain, fatigue)
Cardiovascular (e.g. chest pain, irregular heart beat, high blood pressure)
Ears, Nose, Mouth, Throat (e.g. hearing loss, sinus, vertigo, dry mouth)
Respiratory (e.g. shortness of breath, coughing, asthma, congestion)
Gastrointestinal (e.g. heartburn, abdominal pain, diarrhea, vomiting, ulcers)
Genitourinary (e.g. pain or discomfort, blood in urine, prostate problems)
Musculoskeletal (e.g. muscle ache, joint pain, swollen joints, arthritis)
Integumentary (e.g. rash, excessive dryness, hives, acne)
Neurological (e.g. numbness, weakness, headaches, paralysis, strokes)
Psychiatric (e.g. depression, anxiety, trouble sleeping)
Endocrine (e.g. hypothyroid, hyperthyroid diabetes)
Hematologic/Lymphatic (e.g. cholesterol, anemia, enlarged lymph glands)
Allergic/Immunologic (e.g. hay fever, Lupus, Sjogren's, HIV/AIDS)

Social History
NoYesOther
Never smokedFormer smoker
DailySome days.
½ pack1 pack
YesNo
Drug used
Hobbies/Avocation
Level of education (high school, vocational school, college, BA, BS, graduate degree, etc)
Do you have special visual needs?
Family History

Please indicate if there is a family history of the following medical conditions.
Indicate the relationship to patient: M = mother, F = father, B = brother, S = sister, GM = grandmother, GF = grandfather, U = uncle, A = aunt
Glaucoma
Retinal disease
Cataract
Macular degeneration
Blindness
Strabismus
Other
Diabetes
Cancer
Heart Disease
Hypertension
High Cholesterol
Other
Should be Empty:

Medical History Questionnaire