Medical History Questionnaire | Champlain Ophthalmology

Name: *

Date Of Birth: *

How did you hear about our practice?

What is the purpose of your visit?

List medical conditions, surgeries, or injuries with dates:

List all medications (include eye drops):

List all medication allergies:

Family Medical History (Check all that apply and indicate relationship below)

Relationship (Blindness)

Relationship (Heart Disease)

Relationship (Glaucoma)

Relationship (Arthritis)

Relationship (Auto-immune)

Relationship (Retina)

Relationship (Cancer)

Relationship (Cataract)

Relationship (Diabetes)

Relationship (Macular Degeneration)

Details for other:

Please indicate if you have used any of the following and frequency of consumption:

How often you smoke?

How often you consume alcohol?

What other drugs do you consume and how often?

Have you fallen in the past year?

Have you been vaccinated against COVID-19?

Did you receive a Flu vaccine this year?

Have you received a Pneumococcal vaccine (age>65)?

What is your occupation?

What are your main hobbies?

Do you wear glasses? (indicate if they are for reading, distance, or both)

Do you wear contacts? (indicate what type and how often)

Have you had LASIK, PRK, or other refractive surgery? (indicate where and when)

Review of Systems

Please indicate if you experience any of the following:

Eyes

Other