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Medical Questionnaire For Patients

This medical questionnaire collects information about a patient's medical history including current medications, allergies, illnesses, and family medical history. It asks the patient about any existing problems affecting different body systems like eyes, ears, heart, lungs and others. It also inquires about the patient's social history including alcohol and tobacco use, blood transfusions, and whether any activities are limited by their vision. The patient signs to confirm the accuracy of the provided information which is reviewed and signed by the physician.

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jrepko1
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174 views1 page

Medical Questionnaire For Patients

This medical questionnaire collects information about a patient's medical history including current medications, allergies, illnesses, and family medical history. It asks the patient about any existing problems affecting different body systems like eyes, ears, heart, lungs and others. It also inquires about the patient's social history including alcohol and tobacco use, blood transfusions, and whether any activities are limited by their vision. The patient signs to confirm the accuracy of the provided information which is reviewed and signed by the physician.

Uploaded by

jrepko1
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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MEDICAL QUESTIONNAIRE

Name:__________________________ Date of Birth: Date ________________________________ List any medications you currently take (Rx and over-the-counter): _____________________________________ ____________________________________________________________________________________________

Pharmacy Name:______________________________________________________ (telephone number and address)


Do you have allergies to any medications? YES NO Name(s):____________________________________________ List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, etc.) or injuries (concussion, etc.): Do you currently have any problems in the following areas? If YES, please circle & provide additional information.

PATIENT HISTORY
EYES (poor vision, eye pain, tearing, redness, etc.) GENERAL / CONSTITUTIONAL (fever, heat
stroke, weight loss, weight gain, unusually tired) EARS, NOSE, THROAT (hard of hearing, stuffy nose, earache, cough, dry mouth, etc.) CARDIOVASCULAR (high BP, racing pulse, etc.) RESPIRATORY (congestion, wheezing, short of breath, etc.) GASTROINTESTINAL (stomach upset, diarrhea, constipation, hernia, ulcers, etc.) GENITAL, KIDNEY, BLADDER (painful urination, frequent urination, impotence, yellow jaundice, etc.) FEMALES Are you pregnant? Nursing? MUSCLES, BONES, JOINTS (joint pain, stiffness, swelling, cramps, arthritis, etc.) SKIN (pimples, warts, growths, rash, etc.) NEUROLOGICAL (numbness, headache, seizures, paralysis, etc.) PSYCHIATRIC (anxiety, depression, insomnia) ENDOCRINE (diabetes, hypothyroid, etc.) BLOOD / LYMPH (bleeding, cholesterolemia, anemia, problems related to blood transfusion, etc.) ALLERGIC / IMMUNOLOGIC (sneezing, swelling, redness, itching, hives, lupus, etc.)

YES

NO

Details

FAMILY HISTORY
Other heritable disease:
SOCIAL HISTORY

(Mother, Father, Grandparent, Sibling)

Has any member of your family had these diseases (circle all that apply) ? YES NO UNKNOWN Cataract, Glaucoma, Macular Degeneration, Diabetes, Hypertension, Heart Disease, Stroke, Cancer, Thyroid Disease, Arthritis

Does your vision limit any activities of daily living (driving, reading, sports, work, etc.)? YES NO Have you ever had a blood transfusion? ............ YES NO Do you drink alcohol? ......... YES NO If YES, how much? ___________ Do you smoke? Current or former?..... YES NO If YES, how much? ___________ How many years? ___
Patient Signature:

X_____________________________________________Physicians Signature__________________Date:__________

*Primary Care Physician


____________________ CITY_____________________________________________________

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