CT Center for Sight


History Questionnaire


* Required Information

Name*
Date
Date of Birth*
Date of last eye exam

List any medications you currently take (prescription and over-the-counter):

Do you have allergies to any medication:

If yes, list the medications:

List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, etc.) or injuries (concussion, etc.):

List any surgeries you have had (cataract, tonsillectomy, appendectomy):

Do you currently have any problems in the following areas? (check all that apply)

EYES (Glaucoma, cataract, retinal disease, etc.)    
Loss of vision Blurred vision
Fluctuating 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
Infection of eye or lid (blepharitis, style) Tired eyes
Crossed eyes, lazy eye Dropping eyelid
GENERAL/CONSTITUTIONAL
Fever Weight loss Other
EARS, NOSE, THROAT (Sinus, ear infection, chronic cough, dry mouth, etc.)
CARDIOVASCULAR (Heart, vessels, etc.)
RESPIRATORY (Asthma, emphysema, etc.)
GASTROINTESTINAL (Stomach ulcers, intestinal disease, etc.)
GENITAL, KIDNEY, BLADDER
MUSCLES, BONES, JOINTS (Arthritis, etc.)
SKIN (Acne, warts, skin cancer, etc.)
NEUROLOGICAL (Multiple sclerosis, etc.)
PSYCHIATRIC (Anxiety, depression, insomnia)
ENDOCRINE (Diabetes, hypothyroid, etc.)
BLOOD/LYMPH (cholesterolemia, anemia, etc.)
ALLERGIC/IMMUNOLOGIC (Hey fever, lupus, Sjogrens, etc.)

If you answered "YES" to any of the about please provide information.
FAMILY HISTORY  
DISEASE   RELATIONSHIP TO PATIENT
Blindness
Glaucoma
Arthritis
Cancer
Diabetes
Heart disease or high blood pressure
Kidney disease
Lupus
Stroke
Thyroid disease
Other
SOCIAL HISTORY  
Current Occupation:
Education:
(high school, vocational school, college degree)
Marital Status: Married Divorced Single Widowed
Living Arrangements:
Do you drive?
Do you have visual difficulty when driving?
Do you have problems with night vision?
Have you ever tried to wear contact lenses?
Do you currently wear contact lenses?
If YES, how long have you worn contact lenses?
Do you currently wear glasses?
If YES, how long have you had your current prescription?
Do you drink alcohol? Yes No If YES, Occasionally 1 per day
  2-3 per day 4 or more a day
Do you smoke? Yes No If YES, Occasionally 1/2 pack a day
    1 pack a day more than a pack a day
Have you ever had a blood transfusion? Yes No

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