New Patient Questionnaire

Name

Today's Date

Age

Gender

Height

Date of Birth

Referring Physician

Telephone #

Primary Care Physician

Telephone #

Describe your present vision disorder or eye complaint

If you are using eye drops please list the name, dosage, and directions on how they are being used

Previous Eye Surgeries and/or Lasers (as much information)

General Medical Conditions

General Surgeries

Please list all medications you are currently taking along with the MG and directions on how it's taken (include over the counter and herbal medications)

Family History

Blindness

Yes

No

If yes, please specify relationship

Diabetes

Yes

No

If yes, please specify relationship

High Blood Pressure

Yes

No

If yes, please specify relationship

Macular Degeneration

Yes

No

If yes, please specify relationship

Glaucoma

Yes

No

If yes, please specify relationship

Do you have any of the following problems?

Allergies to medication?

Yes

No

If yes, please describe

Constitutional (fever, weight loss, other)

Yes

No

If yes, please describe

Ears/Nose/Mouth (hearing loss, sinus problems, sore throat, other)

Yes

No

If yes, please describe

Respiratory (asthma, shortness of breath, wheezing, coughing, other)

Yes

No

If yes, please describe

Gastrointestinal (heartburn, abdominal pain, diarrhea, vomiting, other)

Yes

No

If yes, please describe

Genitourinary (urinary problems, blood in the urine, other)

Yes

No

If yes, please describe

Integumentary (skin rashes, excessive dryness)

Yes

No

If yes, please describe

Musculoskeletal (muscle aches, joint pain, swollen joints, other)

Yes

No

If yes, please describe

Neurological (numbness, weakness, headaches, paralysis, other)

Yes

No

If yes, please describe

Hematologic/Lymphatic (blood disorder, leukemia, other)

Yes

No

If yes, please describe

Allergic/Immunologic (hay fever, allergies, other)

Yes

No

If yes, please describe

Endocrine (diabetes, thyroid problems)

Yes

No

If yes, please describe

If diabetic, what is the duration?

Cardiovascular (heart problems, chest pain, heart rate sore throat, other)

Yes

No

If yes, please describe

Psychiatric (depression, anxiety, other)

Yes

No

If yes, please describe

Social History

Occupation

Do you smoke or have you ever smoked?

Yes

No

If YES, how many years?

Years Quit

Do you drink alcohol?

Yes

No

If YES, how much?

Occasional

1 per day

2_3 per day

4+ per day

Additional Comments

Completed by

Date

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