HVC - Medical History Questionnaire

Helderman & Jacobs Vision Center
Medical History Questionnaire

"I thank God everyday for Dr. Helderman helping me see better."
-Carrie Lynn Routt

This medical history questionnaire is also available in PDF format: Medical History Questionnaire PDF

Note: Documents in the PDF file format require Adobe Acrobat Reader software. It can be downloaded for free at Adobe.com.

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This webpage was last updated on October 23, 2006

*Required Fields Contact Information
*First Name
*Last Name
*Home Address 1
Home Address 2
*City
*State
*ZIP Code
*Home Phone	()
Work Phone	()
Cell Phone	()
Email Address

Personal Information
*Date of Birth
*Sex
Medical Doctor's Name
Date of Last Medical Exam
Date of Last Eye Exam
Where Was Your Last Eye Exam At?

Medical History
*Do You Have Allergies to Any Medications?	YES	NO

If YES, Please List Medications That You Are Allergic to
List Any Major Surgeries You Have Had
List All Major Illnesses or Injuries
List Any Medications That You Are Currently Taking

General Health
Please check YES or NO for the following general health questions about yourself. If YES, please explain the condition and write the date the condition began.
General/Constitutional	YES	NO		Date/Description
*Fever
*Weight Loss
*Allergic / Immunologic
*Ears, Nose, Throat
*Cardiovascular
*Respiratory
*Gastrointestinal
*Genital, Kidney, Bladder
*Muscles, Bones, Joints
*Skin
*Neurological
*Psychiatric
*Endocrine
*Blood / Lymph
*Other

Family History
Please check YES or NO if anyone in your immediate family has had any of the following conditions. If YES, please tell the relationship of the family member to you.
DISEASE	YES		NO	Relationship to Patient
				Grandparents	Parents	Aunts/Uncles	Siblings	Cousins	Children
*Blindness
*Glaucoma
*Cataracts
*Cancer
*Diabetes
*Heart Disease or High Blood Pressure
*Kidney Disease
*Lupus
*Stroke
*Thyroid Disease

Social History
Current Occupation
*Do You Live Alone?	YES		NO

*Highest Level of Education Completed
*Marital Status
*Do You Currently Wear Glasses?	YES		NO

If YES, How Old Are Your Current Glasses?
*Do You Currently Wear Contact Lenses?	YES		NO

If YES, How Long Have You Worn Contacts?
*Do You Drive?	YES		NO

*Do You Have Visual Difficulty When Driving?
*Do You Have Problems With Night Vision?
*Have You Ever Had A Blood Transfusion?
*Do You Drink Alcohol?
If YES, How Often?
*Do You Smoke?	YES		NO

If YES, How Much?
*Do You Take Any Drugs That Are Not Prescription or Over-the-Counter?	YES		NO

How Did You Hear About Helderman & Jacobs Vision Center?