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60 Years of Eyecare

Optometry Doctors Gnadt,
Meltzer, Protosow and Tamburro
Call for an Exam (631) 615-7496

Home » Medical History Questionnaire

Medical History Questionnaire

  • MEDICAL HISTORY

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  • FAMILY HISTORY

    Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:
  • SOCIAL HISTORY

  • REVIEW OF SYSTEMS

    Do you currently, or have you ever had any problems in the following areas?
  • NoYes?
    Fever, Weight Loss/Gain
  • NoYes?
    Integumentary (Skin)
  • NoYes?
    Headaches
    Migraines
    Seizures
  • NoYes?
    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/Lid
    Styies or Chalazion
    Flashes/Floaters in Vision
    Tired Eyes
  • NoYes?
    Thyroid/Other Glands
  • NoYes?
    Allergies/Hay Fever
    Sinus Congestion
    Runny Nose
    Post-Nasal Drip
    Chronic Cough
    Dry Throat/Mouth
  • NoYes?
    Asthma
    Chronic Bronchitis
    Emphysema
  • NoYes?
    Diabetes
    Heart Pain
    High Blood Pressure
    Vascular Disease
  • NoYes?
    Diarrhea
    Constipation
  • NoYes?
    Genitals/Kidney/Bladder
  • NoYes?
    Rheumatoid Arthritis
    Muscle Pain
    Joint Pain
  • NoYes?
    Anemia
    Bleeding Problems
  • NoYes?
    Allerical/Immunologic
  • NoYes?
    Psychiatric