Medical Questionnaire

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FOCAL POINT VISION

MEDICAL QUESTIONNAIRE

 PATIENT NAME________________________________________________________

DOB:_______/________/_______

CURRENT MEDICATION LIST:___________________________________________________________________________ ________________________________________________________________________________

 Are you currently using: ____Aspirin    ____ Coumadin   _____ Plavix

 Have you ever used Flomax?    _____

SOCIAL HISTORY - CHECK YES ONLY

____ Alcohol use _____ Tobacco use _____ Can read English    

 _____ Drives motor vehicle

 FAMILY HISTORY - CHECK YES ONLY

____ Blindness   ____ Diabetes_____Cancer ____ Glaucoma

____ Cataracts  ____ Macular Degeneration ____ Crossed Eyes

____ Retinal Detachment

PAST MEDICAL HISTORY -CHECK YES ONLY

____ Arthritis/Joint problems ____ Herpes Simplex

 ____ Asthma ____ High Blood Pressure 

____ Bleeding disorder  ____ History of Eye/Head Injury 

____ Bronchitis/COPD/Emphasema

____ Jaundice/Hepatitis/Liver problems

____ Chronic Headaches  ____ Kidney or Renal problems

____ Diabetes  ____ Lung or breathing problems

____ Disabilities   ____ Migraines ____ Gastritis 

____ Thyroid Disease ____ Stroke or Neurological problems  

____ Ulcers____ Heart Disease _____ Other   

ALLERGIES TO DRUGS / MEDICATIONS:______________________________________________

List any surgery within past year – Specify:                  

____ Amputations: ______________________________

____ Eye: _____________________________________

____ Face: ____________________________________

____ Head: ____________________________________

____ Other: _________________________

REVIEW OF SYSTEMS- CHECK YES ONLY if you have:

____ Unexplained Weight loss/gain          ____ Prostate Problems

____ Fever                        ____ Dialysis/Kidney Problems/Kidney stones

____ Sinus Problems/ allergies       ____ Diabetes

____ Heart Disease Attack   ____ Stroke

____Thyroid Disorder     

____ High Cholesterol  ____ Excessive Bleeding with surgery

____ Chest Pain/Discomfort  ____ Chronic Headaches/Migraines

­­­­____ Psychiatric diagnosis/Depression                                                          

____ Difficulty Breathing/COPD/Asthma    ____ Arthritis or Gout

____ Stomach Pain/Indigestion/Reflux                             

____ Other: ________________________________

 PRIMARY CARE PHYSICIAN : _____________________________

 Form completed by: ___________Relationship______________

PATIENT SIGNATURE: ___________________DATE:___________