Medical History Questionnaire Name* First Last Today’s Date Date Format: 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 Date Format: MM slash DD slash YYYY MaleFemaleMarital StatusSMDWHome Phone*Work PhoneEmail OccupationEmployer or Name of SchoolFulltime StudentPart-time StudentSpouse Name (or Guardian if under 18)Date of Birth Date Format: MM slash DD slash YYYY MaleFemaleAddress if different Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneWork PhoneLast Eye Exam Date Format: MM slash DD slash YYYY OccupationEmployerName of Medical doctorDr's PhoneLast Medical Exam Medical HistoryDo you have any allergies to medications?YesNoexplainList 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?YesNoDo you wear glasses?YesNohow old is your present pair of lenses?Do you wear contact lenses?YesNohow old is your present pair of lenses?Type of contact lensesRigidSoftExtended WearAre they comfortable?YesNoFamily History: Please note any family history (parents, grandparents, siblings, children: living or deceased) for the following conditions DISEASE / CONDITIONBlindnessYesNoUnsureRELATIONSHIP TO YOUCataractYesNoUnsureRELATIONSHIP TO YOUCrossed EyesYesNoUnsureRELATIONSHIP TO YOUGlaucomaYesNoUnsureRELATIONSHIP TO YOUMacular DegenerationYesNoUnsureRELATIONSHIP TO YOURetinal Detachment/DiseaseYesNoUnsureRELATIONSHIP TO YOUArthritisYesNoUnsureRELATIONSHIP TO YOUCancerYesNoUnsureRELATIONSHIP TO YOUDiabetesYesNoUnsureRELATIONSHIP TO YOUHeart DiseaseYesNoUnsureRELATIONSHIP TO YOUHigh Blood PressureYesNoUnsureRELATIONSHIP TO YOUKidney DiseaseYesNoUnsureRELATIONSHIP TO YOULupusYesNoUnsureRELATIONSHIP TO YOUThyroid DiseaseYesNoUnsureRELATIONSHIP TO YOUOtherRELATIONSHIP TO YOUFamily DoctorINSURANCE INFORMATIONMedicare #Vision Insurance CompanyPhoneVision Insurance Company address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Member #Insured's NameRelationship to PatientDate of Birth Date Format: MM slash DD slash YYYY MaleFemaleGroup NumberPrimary Health Insurance CompanyPhonePrimary Health Insurance Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Member #Insured's Namerelationship to PatientDate of Birth Date Format: MM slash DD slash YYYY MaleFemaleGroup 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?YesNodo you have visual difficulty when driving?YesNoplease describeDo you use tobacco products?YesNotype/amount/how longDo you drink alcohol?YesNotype/amount/how longDo you use illegal drugs?YesNotype/amount/how longHave 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.