Medical History Questionnaire

Name: Eye Vision Associates
Address: 271 Smithtown Boulevard, Nesconset, NY, 11767-2041, US
Telephone: (631) 588-5100
Price range: $000 - $300

Name:
First Last
Gender:
- Male
- Female
Today's Date:
MM slash DD slash YYYY
Address:
Street Address Address Line 2 City State ZIP Code
Phone:
Work Phone:
Cell Phone:
Texting OK?
- Yes
- No
Birth Date:
MM slash DD slash YYYY
Social Security Number:
Occupation:
Guardian (if applicable):
Date of Last Eye Exam:
MM slash DD slash YYYY
Name of Medical Doctor:
Doctor's Phone:
Date of Last Medical Exam:
MM slash DD slash YYYY
Pharmacy:
Race:
Preferred Language:
- English
- Spanish
MEDICAL HISTORY
Do you have any allergies to medications?
- Yes
- No
If yes, explain:
List any 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:
Check if you have had any of the following:
- Crossed Eyes
- Lazy Eye
- Drooping Eyelid
- Prominent Eyes
- Glaucoma
- Retinal Disease
- Cataracts
- Eye Infections
- Eye Injury
Are you pregnant and/or nursing?
- No
- Yes
Do you wear glasses?
- No
- Yes
If yes, how old is your present pair of glasses?
Do you wear contact lenses?
- No
- Yes
If yes, how old is your present pair of lenses?
Type of contact lenses:
- Rigid
- Soft
- Extended
Are they comfortable?
- Yes
- No
FAMILY HISTORY
Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions:
Blindness
- No
- Yes
- ?
Relationship to you:
Cataract
- No
- Yes
- ?
Relationship to you:
Crossed Eyes
- No
- Yes
- ?
Relationship to you:
Glaucoma
- No
- Yes
- ?
Relationship to you:
Macular Degeneration
- No
- Yes
- ?
Relationship to you:
Retinal Detachment/Disease
- No
- Yes
- ?
Relationship to you:
Arthritis
- No
- Yes
- ?
Relationship to you:
Cancer
- No
- Yes
- ?
Relationship to you:
Diabetes
- No
- Yes
- ?
Relationship to you:
Heart Disease
- No
- Yes
- ?
Relationship to you:
High Blood Pressure
- No
- Yes
- ?
Relationship to you:
Kidney Disease
- No
- Yes
- ?
Relationship to you:
Lupus
- No
- Yes
- ?
Relationship to you:
Thyroid Disease
- No
- Yes
- ?
Relationship to you:
Other condition:
Relationship to you:
SOCIAL HISTORY
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
- Yes, I would prefer to discuss my Social History information directly with my doctor.
Do you drive?
- No
- Yes
If yes, do you have visual difficulty when driving?
- No
- Yes
If yes, please describe:
Do you use tobacco products?
- No
- Yes
If yes, type/amount/how long:
Do you drink alcohol?
- No
- Yes
If yes, type/amount/how long:
Do you use illegal drugs?
- No
- Yes
If yes, type/amount/how long:
Have you ever been exposed to or infected with:
- Gonorrhea
- Hepatitis
- HIV
- Syphilis
REVIEW OF SYSTEMS
Do you currently, or have you ever had any problems in the following areas?
Constitutional
No Yes ?
Fever, Weight Loss/Gain
Integumentary (Skin)
No Yes ?
Integumentary (Skin)
Neurological
No Yes ?
Headaches
Migraines
Seizures

Eyes

	No	Yes	?
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

Endocrine
No Yes ?
Thyroid/Other Glands
Ears, Nose, Mouth, Throat
No Yes ?
Allergies/Hay Fever
Sinus Congestion
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Throat/Mouth
Respiratory
No Yes ?
Asthma
Chronic Bronchitis
Emphysema
Vascular/Cardiovascular
No Yes ?
Diabetes
Heart Pain
High Blood Pressure
Vascular Disease
Gastrointestinal
No Yes ?
Diarrhea
Constipation
Genitourinary
No Yes ?
Genitals/Kidney/Bladder
Bones/Joints/Muscles
No Yes ?
Rheumatoid Arthritis
Muscle Pain
Joint Pain
Lymphatic/Hematologic
No Yes ?
Anemia
Bleeding Problems
Allerical/Immunologic
No Yes ?
Allerical/Immunologic
Psychiatric
No Yes ?
Psychiatric
If you answered YES to any of the above or have a condition not listed, please explain and list medications:
Patient Signature
Date
MM slash DD slash YYYY

Mask Policy
updated Feb. 16, 2023
In light of New York’s lifting the mask mandate, as of February 12, 2023, masks are no longer considered mandatory at our office.

We still request that any patients or staff who have been around anyone with COVID, RSP, or the Flu, to please, out of respect for all of our patients and staff, continue to wear a mask while in our public space.

We appreciate everyone’s kindness and understanding.

Medical History Questionnaire

MEDICAL HISTORY

FAMILY HISTORY

SOCIAL HISTORY

REVIEW OF SYSTEMS

Q&A with Dr. Meltzer

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Eye Vision Associates

	No	Yes	?
Headaches
Migraines
Seizures

	No	Yes	?
Allergies/Hay Fever
Sinus Congestion
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Throat/Mouth

	No	Yes	?
Asthma
Chronic Bronchitis
Emphysema

	No	Yes	?
Diabetes
Heart Pain
High Blood Pressure
Vascular Disease