MEDICAL HISTORY QUESTIONNAIRE
Guardian (if applicable)
Social Security #
How many years since your last eye exam?
How many years since your last medical exam?
SOCIAL HISTORYThis information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
Do you drive?
If yes, do you have visual difficulty when driving?
Do you use tobacco products?
Do you drink alcohol?
Do you use illegal drugs?
Have you ever been exposed to or infected with:
Have you ever had a blood transfusion?
Do you have any allergies to medications?
List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies)
Are you pregnant and/or nursing?
List all major injuries, surgeries and/or hospitalizations you have had
Do you wear glasses?
Do you wear contact lenses?
Type of contact lenses
Are they comfortable?
Sports & Safety EyewearMany eyeglass and control lens wearers have hobbies and job needs that require a special pair of glasses. We encourage all of our patients to wear Sports/safety eyewear during these activities. The eyewear your receive to wear on a daily basis are dress eyewear only -- they do not meet the Safety Eyewear Standards.
Have you or any of your blood relatives ((living or deceased) had any of the following?
High Blood Pressure
Drooping Eye Lid
Eye Injury or Infections
Other Eye Disease
All EyeCare Services
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At Okaloosa Eye Care , we provide the highest quality eye care to all our patients. Schedule your appointment today.
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