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Medical Questionnaire Form

Dr. David W. Zehnder Vision Health Care Center 1832 Castleton Way Delaware, OH 43015 (740)363-2015 www.zehndervision.com

Your last yearly eye health examination was on: Please make any necessary changes below: Name: Address City, State, Zip Email Address Medical History Questionnaire-Please complete all questions Employer/School: Employer/School Address: Occupation/Job Title : Employer Phone: Medical Insurance Vision Insurance Family Physician Pharmacy Used Social Security # Birth Date   Responsible Party for Minor Child List current medications taking : List any allergies to medications: List any surgeries you have had (cataract, appendectomy, heart, etc....) Date of last physical exam: Do you currently have problems in any of the following areas? If yes, please provide details. Eyes Yes No Details Loss of Vision Blurred Vision Changing focus from near to distance Seeing spots, lines, flashes, halos Light sensitivity (sunshine) Night Glare (headlights) Loss of side vision Double Vision Dryness Mucous Discharge Redness Burning Itching Sandy or gritty feeling Foreign body sensation Excess tearing or watering Eye pain or soreness Infection of eye or lid Tired eyes Crossed eyes, lazy eye Drooping eyelid(s)   GENERAL Yes No Details Ear, Nose, Throat (stuffy nose, ear ache, cough, dry mouth) Cardiovascular (High BP, racing pulse, etc) Neurological (numbness, headache, etc) Endocrine (diabetes, thyroid, etc.) Allergic reaction (sneezing, swelling, redness, itching, hives) Genital, Kidney, Bladder Muscle, Bone, Joints Skin Psychiatric Blood/Lymph General/Constitutional Gastrointestinal   DISEASES Self Family Members Blindness Cataracts Macular Degeneration Glaucoma Cancer Diabetes Heart Disease Stroke Lupus Multiple Sclerosis Arthritis Social History Marital Status (Married, Single, Divorced, Widowed) Do you drive? Yes No ............................. Do you have difficulties when driving? Yes No Have you ever tried contact lenses? Yes No Do you currently wear contact lenses?Yes No ..Brand Name If yes, how long Do you wear protective sunglasses ?Yes No Are you interested in Laser Surgery? Yes No Are you interested in alternatives to Laser Surgery? Yes No Do you use a computer? Yes No ..........Hours/Day Do you drink alcohol? Yes No ...........How Often? Do you smoke? Yes No .................# of Packs/Day Do you use drugs? Yes No A deposit is required on all materials before they are ordered with the balance due on delivery. We will bill a responsible parent for services and materials. However, balances unpaid within 30 days will become the responsibility of the parent accompanying the child to the office. Questions or Additional Information: