Medical Questionnaire

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       _____ Illicit Drug use     _____ Can read English    

 _____ Drives motor vehicle

FAMILY HISTORY - CHECK YES ONLY

____ Blindness                                                                    ____ Diabetes

____ Cancer                                                                         ____ Glaucoma

____ Cataracts                                                                    ____ High blood pressure                                                 

____ Chronic Headaches                                                    ____ Migraines                                   

____ Crossed Eyes                                                              ____ Retinal Detachment

PAST MEDICAL HISTORY -CHECK YES ONLY

____ Arthritis/Joint/Bone problems                 ____ Herpes Simplex                                        

____ Asthma                                                      ____ High Blood Pressure                                

____ Bleeding disorder                                      ____ History of Eye / Head Injury

____ Bronchitis                                                  ____ 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                                             ____ Thyroid Disorder                                                                                      

____ High Cholesterol                                                        ____ Excessive Bleeding with surgery

____ Chest Pain/Discomfort                                              ____ Chronic Headaches/Migraines

____ Stroke                                                                          ­­­­____ Psychiatric problems/Depression                                                          

____ Difficulty Breathing/COPD/Asthma                     ____ Arthritis or Gout

____ Gastro Pain/Indigestion/Reflux                              ____ Other: ________________________________________

PRIMARY CARE PHYSICIAN _____________________________________________________________________________

Form completed by _____________________________________________   Relationship________________________________

PATIENT SIGNATURE: _______________________________________________   DATE:____________________________

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