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Maple Valley Vision Maple Valley Vision
Maple Valley Vision Maple Valley Vision
 

Medical History Questionnaire


Please fill out our patient registration form. You may send it to us, print it out and bring it with you, or come early to your appointment and fill one out at our office.
Please fill out all fields for submission - all information is secure and strictly confidential for your protection.

Name*
Address*
City*
State*
Zip*
Phone (Primary)*
Phone (Alternate)
Guardian (If Applicable)
Occupation
Date of Birth*
Social Security #
Last Eye Exam
Name of Medical Doctor
Doctor's Phone
Last Medical Exam

Medical History
Do you have any allergies to medications?*
If yes, explain
List and medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies).
List all major injuries, surgeries and/or hospitalizations you have had
List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections or eye injury
Are you pregnant and/or nursing?*
Do you wear glasses?*
If yes, how old is your present pair of lenses?
Do you wear contact lenses?*
If yes, how old is your present pair of lenses?
Type of contact lenses?
Rigid
Soft
Extended Wear
Other
Are they comfortable?*

Family History

Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:
Blindness*
Cataract*
Crossed Eyes*
Glaucoma*
Macular Degeneration*
Retinal Detachment/Disease*
Arthritis*
Cancer*
Diabetes*
Heart Disease*
High Blood Pressure*
Kidney Disease*
Lupus*
Thyroid Disease*

Social History

This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
I would prefer to discuss my Social History information directly with my doctor.
Yes
Do you drive?
Yes
No
If yes, please describe any visual difficulty when driving.
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

Review of Systems

Do you currently, or have you ever had any problems in the following areas:

Constitutional
Fever, Weight Loss/Gain*

Integumentary
Skin problems*

Eyes
Loss of Vision*
Blurred Vision*
Distorted Vision/Halos*
Loss of Side Vision*
Double Vision*
Dryness*
Mucous Discharge*
Redness*
Sandy or Gritty Feeling*
Itching*
Burning*
Foreign Body Sensation*
Excess Tearing/Watering*
Glare/Light Sensitivity*
Eye Pain or Soreness*
Chronic Infection of Eye or Lid*
Sties or Chalazion*
Flashes/Floaters in Vision*
Tired Eyes*

Endocrine
Thyroid/Other Glands*

Ears, Nose, Mouth, Throat
Allergies/Hay Fever*
Sinus Congestion*
Chronic Cough*
Dry Throat/Mouth*

Respiratory
Asthma*
Chronic Bronchitis*
Emphysema*

Vascular/Cardiovascular
Diabetes*
Heart Pain*
High Blood Pressure*
Vascular Disease*

Gastrointestinal
Diarrhea/Constipation*

Genitourinary
Genitals/Kidney/Bladder*

Bones/Joints/Muscles
Rheumatoid Arthritis*
Muscle Pain*
Joint Pain*

Lymphatic/Hematologic
Anemia*
Bleeding Problems*
Allergic/Immunologic/Psychiatric*
If you answered YES to any of the above or have a condition not listed, please explain & list medications:
Email*

* = Required fields