CochiseEye.com - Medical/Surgical/Family History Questionnaire


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Medical/Surgical/Family History Questionnaire
Please fill out this important medical questionnaire and return it to the correct office location
at least 2 days prior to your appointment. You can fill this out online with this form and a copy will be sent to your email. You can then print the copy, sign it and bring it in with you on your visit.

Printable Version	Office Locations: 2445 E. Wilcox Dr. - Sierra Vista, AZ 85635 - (520) 458-8131 4116 Avenida Cochise, Suite # A - Sierra Vista, AZ 85635 - (520) 452-1125 880 W. 4th St., Suite # 3 - Benson, AZ 85602 - (520) 586-7877

Patient Name:
Email Address:

1.)

Please choose the appropriate type of appointment that was made:
If a referral or consultant, include Dr's name and reason for appointment:

2.)

Your primary care physician (Family Doctor) is:

3.)

Allergies (medication or food), & what type of allergic reaction it caused:

4.)

Previous Ophthalmologist / Optometrist:
Address (if known):

5.)

Medical conditions/illnesses (with or without treatment) & year diagnosed:

6.)

Eye conditions diagnosed, which eye(s) are involved & year diagnosed:

7.)

Previous Eye Injuries: (type of injury, which eye, year injury occurred):

8.)

Previous eye or eyelid surgery, eye(s) or lids(s) involved, year surgery performed, surgeon
name and location (city & state)

9.)

Previous major surgeries, type of surgery, year surgery performed:
(examples: Gallbladder removed 1990, Appendix removed 1980)

10.)

Social History:
Marital status:
Do you drive a motorized vehicle:
Do you use or consume the following products:
Tobacco:    Year started:      Quantity per day:
Alcohol:    Year started:    Frequency:
Illegal Drugs:    Frequency:

11.)

Family History of eye or medical conditions/illnesses:
(examples: glaucoma-father, diabetes-sister, high blood pressure-mother)

12.)

Current Medications being taken: Name - Dose - Frequency taken:
(include: over the counter meds, oral contraceptives, vitamins & herbals)

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Patient Signature