ABOUT SSL CERTIFICATES

Insight Eye Care
Patient Medical History Questionnaire

  
PERSONAL INFORMATION
First Name: Gender:Male Female   Today's Date: 06/09/2026
Last Name: Preferred Name:  
Address:
City/State/Zip:   
Day Phone: Work Phone: Cell Phone:
Birth Date: (mm/dd/yyyy) Social Security Number: -- E-mail:
Occupation: Primary Care Physician: Last Eye Exam: (mm/dd/yyyy)
Referred By:        
INSURANCE INFORMATION
Medical (Primary):
 Relationship to Insured:
 Insured ID#: 
Insured Name: 
Insured SSN: 
Insured DOB: 
Policy Group#: 
Policy Type:
Medical (Secondary):
 Relationship to Insured:
 Insured ID#: 
Insured Name: 
Insured SSN: 
Insured DOB: 
Policy Group#: 
Policy Type:
Vision Ins:
 Relationship to Insured:
 Insured ID#: 
Insured Name: 
Insured SSN: 
Insured DOB: 
Policy Group#: 
Policy Type:
Please have cards ready for verification
MEDICAL HISTORY
ALLERGIES TO MEDICATIONS

List any known allergies to medications.

MEDICATIONS

List any medications you take. Please include ALL medications, including contraceptives and over-the-counter medications.

SURGERIES & HOSPITALIZATIONS

List all major surgeries, injuries and/or hospitalizations you have had.

Do you have, or have you had, any of the following? If so, explain when you were diagnosed or treated.
 Crossed Eyes   Lazy Eye   Eye Infection 
 Drooping eyelids   Surgery   Eye Injury 
 Cataracts   Retinal hole/tear   Macular Degeneration 
Are you pregnant or nursing?Yes No
Do you currently wear glasses?Yes No
How old are your glasses? 
Do you wear contact lenses?Yes No
Type of lenses:Rigid Soft Other
Are your contacts comfortable?Yes No
How frequently do you replace your contacts? 
FAMILY HISTORY
Please note any family history of the following conditions:
Disease / Condition:
NO YES ?
RELATIONSHIP TO YOU:
Blindness
Cataract
Crossed Eyes
Glaucoma
Macular Degeneration
Retinal Detachment/Disease
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Lupus
Thyroid Disease
Other
SOCIAL HISTORY
This information is kept strictly confidential. If you prefer, you may discuss this information directly with the doctor.
Yes, I would prefer to discuss my Social History information directly with my doctor
Do you have visual difficulty when driving? No Yes If yes, explain: 
Do you use tobacco products? No Yes If yes, type/amount/how long: 
Do you use illegal drugs? No Yes If yes, type/amount/how long: 
Do you drink alcohol? No Yes If yes, type/amount/how long: 
Have you ever been exposed to or infected with:  Gonorrhea  Hepatitis  HIV Syphilis
REVIEW OF SYSTEMS
Please indicate any problem you have or have had in any of the following areas:
No Yes ?
CONSTITUTIONAL
Fever, Weight Loss/Gain
Integumentary (skin)
NEUROLOGICAL
Headaches
Migraines
Seizures
EYES
Loss of Vision
Blurred Vision
Distorted Vision/Halos
Loss of Side Vision
Double Vision
Dryness
Mucous Discharge
Redness
Sandy or Gritty Feeling
Itching
Burning
Foreign Body Sensation
Excess Tearing / Watering
Glare / Light Sensitivity
Eye Pain or Soreness
Chronic Infection of Eye or Lid
Styes or Chalazia
Flashes / Floaters in Vision
Tired Eyes
Glaucoma
GENITOURINARY
Kidney / Bladder / Genitalia
 
No Yes ?
EARS, NOSE, MOUTH, THROAT
Allergies/Hay Fever
Sinus Congestion
Runny Nose
Post-Nasal Drip
Chronic Cough
Dry Throat/Mouth
RESPITORY
Asthma
Chronic Bronchitis
Emphysema
VASCULAR / CARDIOVASCULAR
Diabetes
Heart Pain
High Blood Pressure
Vascular Disease
GASTROINTESTINAL
Stomach / Intestines
BONES / JOINTS / MUSCLES
Rheumatoid Arthritis
Muscle Pain
Joint Pain
LYMPHATIC / HEMATOLOGIC
Anemia
Bleeding Problems
Allergic / Immunologic
ENDOCRINE
     
Thyroid / Other Glands
PSYCHIATRIC
Depression / Anxiety / Agitation