Medical History Questionnaire

PATIENT INFORMATION

MEDICAL HISTORY QUESTIONNAIRE

Please list any medications that you take. (Name, dosage, times taken) Please include oral contraceptives, aspirins, or over the counter medications)

Please list all major injuries, surgeries, and/or hospitalizations you have had:

Have you had cataract surgery? Please list name of surgeon.

Pregnant or nursing?

Do you wear glasses?

Do you wear contact lenses?

Do you experience issues when wearing contact lenses?

SOCIAL HISTORY

This information is kept confidential. However, you may choose to discuss this portion directly with the doctor if you prefer.

Do you drive?

Do you smoke or vape?

Do you drink alcohol?

Have you been exposed or infected with:

SYMPTOM SURVEY

Patient Instructions: Please answer the following questions about how your eyes feel when reading or doing close work.

NOTE: If patient is a child, please read the instructions and then each item exactly as written. If a patient responds with a "yes" please qualify with frequency choices. Do not give examples.

PATIENT QUESTIONS

1) Do your eyes feel tired when reading or doing close work?

2) Do your eyes feel uncomfortable when reading or doing close work?

3) Do you have headaches when reading ordoing close work?

4) Do you feel sleepy when reading ordoing close work?

5) Do you lose concentration when reading ordoing close work?

6) Do you have trouble remembering what you have read?

7) Do you have double vision when reading ordoing close work?

8) Do you see the words move, jump, swim orappear to float on the page when reading ordoing close work?

9) Do you feel like you read slowly?

10) Do your eyes ever hurt when reading ordoing close work?

11) Do your eyes ever feel sore when reading or doing close work?

12) Do you feel a "pulling" feeling around your eyes when reading ordoing close work?

13) Do you notice the words blurring orcoming in and out of focus when reading ordoing close work?

14) Do you lose your place when reading ordoing close work?

15) Do you have to reread the same line of words when reading?

Total Score:

REVIEW OF SYMPTOMS

Do you currently have or been previously diagnosed with any problems in the following areas?

​​​​​​​Please indicate if any family members have any of the below issues in the space at the bottom of this page:

CONSTITUTIONAL:

Fever or Weight Loss/Gain:

NEUROLOGICAL

Headaches/Migraine:

Concussion:

Epilepsy:

Multiple Sclerosis:

Alzheimer’s:

EYES

Blurred Vision:

Glaucoma:

Macular Degeneration:

Double Vision

Dryness/Itchy:

Excess Tearing/Watery:

Glare/Light Sensitivity:

Eye Strain/Pain/Soreness:

Flashers/Floaters:

ENDOCRINE:

Thyroid/Other Glands:

Diabetes:

PSYCHIATRIC

Anxiety/Depression:

ALLERGIC/IMMUNOLOGIC

Allergies/Hay Fever:

EARS, NOSE, THROAT, MOUTH:

Sinus Congestion

Chronic Cough:

Runny Nose/Post Nasal Drip:

Dry Throat/Mouth:

RESPIRATORY:

Asthma:

Chronic Bronchitis:

Emphysema/COPD:

VASCULAR/CARDIOVASCULAR:

Heart Disease:

High Blood Pressure:

Stroke:

GASTROINTESTINAL:

Crohn’s Disease:

Colitis:

Ulcer:

GENITOURINARY

Genitals/Kidney/Bladder:

BONES/JOINTS/MUSCLES:

Rheumatoid Arthritis:

Fibromyalgia:

Muscular Dystrophy:

LYMPHATIC/HEMATOLOGIC:

Anemia/Bleeding Problems:

Leukemia:

**If you answered YES to any of the above or have a condition not listed, please explain:

**I confirm that I have filled out this form to the best of my ability and authorize Sibley Eye Care to review and utilize this information for my vision care.**

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