Wufoo
Ragan Family Eye Care, LLC
Medical History Questionnaire
Name
Title
First
Last
Suffix
Today's Date
MM
/
DD
/
YYYY
Date of Birth
MM
/
DD
/
YYYY
Social Security Number
Last Eye Exam
MM
/
DD
/
YYYY
Address
Home Phone Number
###
-
###
-
####
Work Phone Number
###
-
###
-
####
Occupation
Last Eye Doctor
Last Medical Exam
Current Medical Doctor
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 Any of the following that you have had
crossed eyes
lazy eye
glaucoma
retinal disease
cataracts
eye injury
Are you pregnant and/or nursing?
Yes
No
Do you wear glasses?
Yes
No
If yes, how old is you present pair of lenses?
Do you wear contact lenses?
Yes
No
If yes, how old is you present pair of lenses?
Type of contact lenses
Rigid
Soft
Extended Wear
Other
Are they comfortable?
Yes
No
Have you had refractive surgery?
Yes
No
Family History
A description of the section goes here.
Ocular Disease/Condition
Yes
No
Not Sure
Blindness
1
2
3
Cataract
1
2
3
Crossed Eyes
1
2
3
Glaucoma
1
2
3
Macular Degeneration
1
2
3
Retinal Detachment/Disease
1
2
3
Systemic Disease/Condition
Yes
No
Not Sure
Arthritis
1
2
3
Cancer
1
2
3
Diabetes
1
2
3
Heart Disease
1
2
3
High Blood Pressure
1
2
3
Kidney Disease
1
2
3
Lupus
1
2
3
Thyroid Disease
1
2
3
Other
How did you first hear about us?
I was referred here by:
Through my insurance, which is:
I found you myself, here's how:
(Check All That Apply) At any point in your decision making process, did you:
Visit our web site
Visit our Facebook page
Search for us on your insurance web site
Search for us on Google (or Yahoo/Bing)
Visit our Yelp page
Read any online reviews about us
Social History
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
I would prefer to discuss my Social History information directly with my doctor
Do you drive?
Yes
No
If yes, do you have visual difficulty when driving?
Yes
No
If yes, please describe:
Do you use tobacco products?
Yes
No
If yes, type/amount/how long:
Do you drink alcohol?
Yes
No
If yes, type/amount/how long:
Do you use illegal drugs?
Yes
No
If yes, type/amount/how long:
Have you ever been exposed to or infected with:
Gonorrhea
Hepatitis
HIV
Syphilis
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