Get Medical Questionnaire

Completing the Medical Questionnaire online is a straightforward process that helps ensure you receive the best possible care. By providing accurate and detailed information, you enable healthcare professionals to understand your medical history and needs.

Follow the steps to complete your Medical Questionnaire online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date in the specified format: day, month, and year. Make sure to answer the following personal information fields, including the patient's name, social security number, date of birth, driver's license number, sex, race, address, and contact numbers.
3. Next, you will need to provide details about the patient's occupation and employer, as well as an emergency contact person's name, phone number, and their relationship to the patient.
4. Indicate who is responsible for payment of services, providing their name, address, contact number, and relationship to the patient.
5. For referrals, specify the source that directed you to this office, including the name of any referring physician, their address, and phone number if applicable.
6. In the eye history section, list all eye diseases and conditions affecting both the left and right eyes, along with the month and year of diagnosis.
7. If applicable, provide details about any eye surgeries you've had, including dates for each eye.
8. List any eye medications currently being used, specifying which eye they are for, frequency of use, and duration.
9. Indicate whether you wear glasses or contact lenses, including the frequency and details of your last change.
10. Complete the general medical history section, detailing current and past illnesses in chronological order, as well as previous surgical procedures and their dates.
11. Specify any medications currently being taken, their dosages, and frequency of use. Note any drug allergies, if applicable.
12. Answer questions regarding recent symptoms or problems, checking yes or no for various health issues listed.
13. Fill out the personal history section by selecting your marital status and providing information regarding alcohol, smoking, street drug use, and dietary restrictions.
14. In the family history section, indicate if any family members have eye diseases, specifying their relationship to you and the type of condition.
15. After completing all sections, review your entries for accuracy. Finally, save your changes, and consider downloading, printing, or sharing the form as needed.

Complete your Medical Questionnaire online to ensure you receive the right care!