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Captures full legal name, visit status, referral source, and eye exam history. Includes sections for primary care doctor, current medications and allergies, prior eye procedures, and a checklist of symptoms or conditions across multiple body systems (e.g., cardiovascular, respiratory, gastrointestinal, neurological). Also requests family history for eye and chronic diseases, plus smoking, work, pregnancy, and driving status.",{"@graph":63,"@context":110},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/medical-history-questionnaire/306989/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/medical-history-questionnaire/306989.png","ImageObject",442,249,{"name":88,"@type":89},"Adam","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-27","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":20},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104],{"name":105,"@type":106,"acceptedAnswer":107},"Does the questionnaire collect family and lifestyle history?","Question",{"text":108,"@type":109},"Yes. It asks about blood relatives with specific conditions, and includes questions on smoking, whether the patient works, pregnancy, and whether the patient drives.","Answer","https://schema.org",{"og:url":78,"og:type":112,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":114,"canonical":78},"index,follow",{"doc_id":116,"site_id":56},306989,1789842922,{"code":4,"msg":5,"data":119},{"doc_id":116,"user_id":120,"nickname":88,"user_avatar":121,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":122,"file_id":123,"file_url":124,"file_type":125,"file_size":126,"view_count":20,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":127,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":128,"faqs":129,"seo_title":130,"seo_description":61,"update_tm":117,"read_time":4},1374404737137,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","# MEDICAL HISTORY QUESTIONNAIRE\n\n\n| Full Legal Name:  \u003Cbr>Date:  \u003Cbr>Sex:□M □F   |\n| --- |\n\n\n| If this is your first visit,please complete:   |\n| --- |\n| How did you hear about us?   Doctor□Friend       Family Member  \u003Cbr>□Internet   |\n| □Other:   |\n| Where was this done(Dr./Clinic):  \u003Cbr>Date of last eye exam:   |\n\n\n| PRIMARY CARE DOCTOR:   |\n| --- |\n| □Plavix  \u003Cbr>□Coumadin  \u003Cbr>□Flomax  \u003Cbr>□Rapaflow  \u003Cbr>□Aspirin  \u003Cbr>Are you currently taking:   |\n| ]Uroxatral □Minipress  \u003Cbr>□Hytrin  \u003Cbr>Avodart  \u003Cbr>□Cardura   |\n\n\n| Current Medications(prescription,over the counter,vitamins,homeopathic):   |\n| --- |\n|  |\n|  |\n| Allergies to medications:   |\n|  |\n| Have you ever had any of the following eye procedures:  \u003Cbr>□PRK  \u003Cbr>□LASIK  \u003Cbr>□RK   |\n| List allcurrent &previous illnesses,injuries,surgeries:   |\n|  |\n\nPlease check any of the following conditions that you have today:  \n\n| □Cancer  \u003Cbr>Fatigue  \u003Cbr>Fever  \u003Cbr>General:   |\n| --- |\n| □Pain  \u003Cbr>Nasal Congestion  \u003Cbr>□earache  \u003Cbr>Ears,Nose,Throat:   |\n| irregular/rapid heartbeat  \u003Cbr>Cardiovascular:  \u003Cbr>high blood pressure  \u003Cbr>□chest pain   |\n| ]emphysema  \u003Cbr>□asthma  \u003Cbr>shortness of breath  \u003Cbr>Respiratory:   |\n| □vomiting  \u003Cbr>diarrhea  \u003Cbr>□reflux  \u003Cbr>Gastrointestinal:   |\n| □ulcer  \u003Cbr>discharge  \u003Cbr>□trouble urinating  \u003Cbr>Genitourinary:   |\n| □eczema  \u003Cbr>acne  \u003Cbr>□skin cancer  \u003Cbr>Integumentary:  \u003Cbr>□rosacea   |\n| □join/muscle pain  \u003Cbr>□arthritis  \u003Cbr>gout  \u003Cbr>Musculoskelatal:   |\n| □numbness  \u003Cbr>□dizziness  \u003Cbr>]memory loss  \u003Cbr>□stroke  \u003Cbr>Neurological:   |\n| depression  \u003Cbr>□anxiety  \u003Cbr>Psychiatric:   |\n| Grave's disease  \u003Cbr>hypothyroidism  \u003Cbr>diabetes  \u003Cbr>Endocrine:   |\n| high cholesterol  \u003Cbr>bleeding disorder  \u003Cbr>Hematologic:  \u003Cbr>anemia   |\n| ]immune disorder  \u003Cbr>□allergies  \u003Cbr>Immunologic:   |\n\n*Any blood relatives with following conditions:  \n\n| Blindness:   |\n| --- |\n| Glaucoma:   |\n| Macular Degeneration:   |\n| Diabetes:   |\n| Retinal Detachment:   |\n| □No  \u003Cbr>□Yes  \u003Cbr>Previously  \u003Cbr>Smoke?   |\n| □No  \u003Cbr>□No  \u003Cbr>□Yes  \u003Cbr>Do you work?□Yes  \u003Cbr>No  \u003Cbr>Are you pregnant?  \u003Cbr>Drive?  \u003Cbr>□Yes   |","cbCailXagzexRIrj","https://ap.wps.com/l/cbCailXagzexRIrj","pdf",1164369,"English","# Patient Identification & Visit Information\n# Referral, Location, and Eye Exam History\n# Primary Care Doctor, Medications, and Allergies\n# Prior Eye Procedures and Past Illnesses\n# Current Conditions by Body System\n# Family History and Lifestyle Questions","[{\"question\":\"Does the questionnaire collect family and lifestyle history?\",\"answer\":\"Yes. It asks about blood relatives with specific conditions, and includes questions on smoking, whether the patient works, pregnancy, and whether the patient drives.\"}]","Medical History Questionnaire | PDF"]