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)

Medication Allergies

Family Medical History (Check all that apply)

Relationship (Blindness)

Relationship (Heart Disease)

Relationship (Glaucoma)

Relationship (Arthritis)

Relationship (Auto-immune)

Relationship (Retina)

Relationship (Cancer)

Relationship (Cataract)

Relationship (Diabetes)

Relationship (Mascular 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.

List details for drugs

Have you fallen in the past year?

Injury Detials

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