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Eye Care Services
About Ortiz Eye & Hearing
- Education for Profession
Eyeglasses & Contact Lenses
Insurance and Payments
Ortiz Hearing Center, Inc.

Home » Contact Us » Medical History Questionnaire

Medical History Questionnaire

Name(Required)

First Last

DOB

Date of last eye exam:

MM slash DD slash YYYY

REVIEW OF HEALTH SYSTEMS

EYES-

Have you had or do you have any of the following?

Glaucoma

YES

NO

Explain:

Cataracts

YES

NO

Explain:

Dry Eyes

YES

NO

Explain:

Glasses

YES

NO

Explain:

Contacts

YES

NO

Explain:

Other Eye Problems

YES

NO

Explain:

Please describe any problems with the following health systems:

Gastrointestinal-

Ulcer

YES

NO

Colitis

YES

NO

Heartburn

YES

NO

Diarrhea

YES

NO

No Problem

YES

NO

Other:

Meds:

Neurological-

Epilepsy

YES

NO

Multiple Sclerosis

YES

NO

Headaches

YES

NO

Numbness

YES

NO

No Problem

YES

NO

Other:

Meds:

Ears/Nose/Throat-

Upper Respiratory Infection

YES

NO

Sinusitis

YES

NO

Chronic Colds

YES

NO

No Problem

YES

NO

Other:

Meds:

Constitutional-

Fever

YES

NO

Weight Loss

YES

NO

Fatigue

YES

NO

Developmental Disability

YES

NO

Trauma

YES

NO

No Problem

YES

NO

Other:

Meds:

Cardiovascular-

High Blood Pressure

YES

NO

Heart Disease

YES

NO

Vascular Disease

YES

NO

Stroke

YES

NO

High Cholesterol

YES

NO

Chest Pain

YES

NO

Irregular Heart Beat

YES

NO

No Problem

YES

NO

Other:

Meds:

Musculoskeletal-

Muscular Dystrophy

YES

NO

Osteoarthritis

YES

NO

Joint Pain

YES

NO

Muscle Aches

YES

NO

No Problem

YES

NO

Other:

Meds:

Respiratory-

Asthma

YES

NO

Bronchitis

YES

NO

Emphysema

YES

NO

Wheezing

YES

NO

Coughing

YES

NO

No Problem

YES

NO

Other:

Meds:

Integumentary (SKIN)-

Psoriasis

YES

NO

Eczema

YES

NO

Rashes

YES

NO

Acne

YES

NO

Cancer

YES

NO

Excessive Dryness

YES

NO

No Problem

YES

NO

Other:

Meds:

Allergic/Immune-

No Problem

YES

NO

Rheumatoid Arthritis

YES

NO

Lupus

YES

NO

HIV

YES

NO

Allergies:

Drug Allergies:

Endocrine (GLANDS)-

Thyroid Dysfunction

YES

NO

Hormonal Dysfunction

YES

NO

Type 1 Diabetes

YES

NO

Type 2 Diabetes

YES

NO

No Problem

YES

NO

Meds:

Blood/Lymph-

Anemia

YES

NO

Leukemia

YES

NO

No Problem

YES

NO

Other:

Meds:

Psychiatric (MENTAL)-

Depression

YES

NO

Bipolar

YES

NO

ADD/ADHD

YES

NO

No Problem

YES

NO

Other:

Meds:

Genitourinary-

STD

YES

NO

Bladder Infection

YES

NO

Blood in Urine

YES

NO

No Problem

YES

NO

Other:

Meds:

PAST FAMILY & SOCIAL HISTORY

Patient Past History-

Have you had any eye operations?

YES

NO

Type:

Date

MM slash DD slash YYYY

Have you had an eye injury?

YES

NO

Untitled

Date

MM slash DD slash YYYY

Have you had a retinal detachment?

YES

NO

Type:

Date

MM slash DD slash YYYY

Name of family doctor?

Referring Physician:

Are you pregnant or nursing?

List any eye medications you are currently taking:

Social History-

Do you use alcohol?

YES

NO

Amount:

Smoking Status:

Current every day smoker

Current some day smoker

Former smoker

Never smoked

Unknown

Do you use other substances?

YES

NO

What:

Describe any special visual needs:

Family History-

Do any family members have any of the following problems:

High blood pressure

YES

NO

Relation:

Diabetes

YES

NO

Relation:

Macular Degeneration

YES

NO

Relation:

Retinal Detachment

YES

NO

Relation:

Cataracts

YES

NO

Relation:

Other eye condition

YES

NO

Relation:

Description:

Patient Signature:

Date

MM slash DD slash YYYY

Δ

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Patient History Form

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Follow Us

Ortiz Eye Associates

880 Bedford Rd
Morris, IL 60450

Phone: (815) 942-5500

Monday: 8:00 AM - 5:00 PM
Tuesday: 8:00 AM - 5:00 PM
Wednesday: 8:00 AM - 5:00 PM
Thursday: 9:00 AM - 6:00 PM
Friday: 8:00 AM - 5:00 PM
Saturday: Limited Saturday hours. Please Call ahead
Sunday: Closed

Ortiz Eye Associates - Located at 880 Bedford Rd, Morris, IL 60450. Phone: (815) 942-5500. https://www.ortizeye.com

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