Medical History Questionnaire Name* First Last HiddenToday’s Date MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country AgeDate of Birth MM slash DD slash YYYY Male Female Marital Status S M D W Home Phone*Work PhoneEmail Occupation Employer or Name of School Fulltime Student Part-time Student Spouse Name (or Guardian if under 18) Date of Birth MM slash DD slash YYYY Male Female Address if different Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneWork PhoneLast Eye Exam MM slash DD slash YYYY Occupation Employer Name of Medical doctor Dr's Phone Last Medical Exam Medical HistoryDo you have any allergies to medications? Yes No explain List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies) List all major injuries, surgeries and/or hospitalizations you have had List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections or eye injury Are you pregnant and/or nursing? Yes No Do you wear glasses? Yes No how old is your present pair of lenses? Do you wear contact lenses? Yes No how old is your present pair of lenses? Type of contact lenses Rigid Soft Extended Wear Are they comfortable? Yes No Family History: Please note any family history (parents, grandparents, siblings, children: living or deceased) for the following conditions DISEASE / CONDITIONBlindness Yes No Unsure RELATIONSHIP TO YOU Cataract Yes No Unsure RELATIONSHIP TO YOU Crossed Eyes Yes No Unsure RELATIONSHIP TO YOU Glaucoma Yes No Unsure RELATIONSHIP TO YOU Macular Degeneration Yes No Unsure RELATIONSHIP TO YOU Retinal Detachment/Disease Yes No Unsure RELATIONSHIP TO YOU Arthritis Yes No Unsure RELATIONSHIP TO YOU Cancer Yes No Unsure RELATIONSHIP TO YOU Diabetes Yes No Unsure RELATIONSHIP TO YOU Heart Disease Yes No Unsure RELATIONSHIP TO YOU High Blood Pressure Yes No Unsure RELATIONSHIP TO YOU Kidney Disease Yes No Unsure RELATIONSHIP TO YOU Lupus Yes No Unsure RELATIONSHIP TO YOU Thyroid Disease Yes No Unsure RELATIONSHIP TO YOU Other RELATIONSHIP TO YOU Family Doctor INSURANCE INFORMATIONMedicare #Vision Insurance Company PhoneVision Insurance Company address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Member #Insured's Name Relationship to Patient Date of Birth MM slash DD slash YYYY Male Female Group NumberPrimary Health Insurance Company PhonePrimary Health Insurance Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Member #Insured's Name relationship to Patient Date of Birth MM slash DD slash YYYY Male Female Group Number * understand that I am responsible for all financial obligations of health services and for reimbursement and payment of claims from m Insurance Company. If for any reason the account should become delinquent, I agree to pay for all billing charges, collection costs and reasonable legal fees. Also, I understand that to reschedule or cancel an appointment - 2 business day notification prior to the appointment is requested.Signed: (Parent or Guardian)Social HistorySocial History This information is dept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer. Yes, I would prefer to discuss my Social History information directly with my doctor.Do you drive? Yes No do you have visual difficulty when driving? Yes No please describe Do you use tobacco products? Yes No type/amount/how long Do you drink alcohol? Yes No type/amount/how long Do you use illegal drugs? Yes No type/amount/how long Have you ever been exposed to or infected with Gonorrhea Hepatitis HIV Syphilis Review of systemsDo you currently, or have you ever had any problems in the following areas: SYSTEM CONSTITUTIONALYesNo?Fever, Weight Loss/GainINTEGUMENTARY (Skin)YesNo?NEUROLOGICALYesNo?HeadachesMigrainesSeizuresEYESYesNo?Loss of VisionBlurred VisionDistorted Vision/HalosLoss of side VisionDouble VisionDrynessMucous DischargeRednessSandy or Gritty FeelingItchingBurningForeign Body SensationExcess Tearing/ WateringGlare/Light SensitivityEye Pain or SorenessChronic Infection of Eye or LidSties or ChalazionFlashes/Floaters in VisionTired EyesENDOCRINEYesNo?Thyroid/Other GlandsFever, Weight Loss/GainFever, Weight Loss/GainEARS, NOSE, MOUTH, THROATYesNo?Allergies/Hay FeverSinus CongestionRunny NosePost-Nasal DripChronic CoughDry Throat / MouthRESPIRATORYYesNo?AsthmaChronic BronchitisRunny NoseEmphysemaVASCULAR/CARDIOVASCULARYesNo?DiabetesHeart PainHigh Blood PressureVascular DiseaseGASTROINTESTINALYesNo?DiarrheaConstipationGENITOURINARYYesNo?Genitals/Kidney/BladderBONES / JOINTS / MUSCLESYesNo?Rheumatoid ArthritisMuscle PainJoint PainLYMPHATIC / HEMATOLOGICYesNo?AnemiaBleeding ProblemsALLERGIC/AAMMUNOLOGICYesNo?PSYCHIATRICYesNo?if you answered YES to any of the above or have a condition not listed, please explain & list medications
Dr. Maurillo is available one day a week at Optivision in Cortland. Please call (607)753-7514 for an appointment or visit: Optivision.