HEALTH QUESTIONNARE
 
 
  Please complete the fields below:
     
  Full Name
  Date of birth
  Address
  Nationality
  Home language
  Cell no
  Emergency no
  employer
  Occupation
  Work telephone no
  Email
  Family doctor
  If under 18, Parent/Guardian Full names
  Work no
  Occupation
  Relationship to patient
     
  Please enter your sex in the Text Box below:
 
   
  Please enter your marital status in the Text Box below:
 
   
  Please enter your ethnic group in the Text Box below:
 
   
  Please enter your medical aid details below:
     
  Medical Scheme
  Option
  Medical scheme no
     
  Allergies:
 
   
  Past eye history
     
  Overall healthy
  Amblyopia(lazy eye)
  Cataracts
  Diabetic retinopathy
  Dry eyes
  Glaucoma
  Keratoconus
  Macular degeneration
  Myopia
  Optic neuritis
  Retinal detachment
   
  Other: please specify
   
 
   
  Past eye surgery
     
  No prior eye surgery
  Blepharoplasty
  Cataract surgery
  Corneal surgery
  Foreign body removal
  Retinal laser surgery
  Lasik (refracive surgery)
  Prk(refractive surgery)
  Glaucoma surgery
     
  Other, please specify
   
 
   
  Eye significant illnesses
     
  Overall healthy
  Aids
  Diabetis
  Rheamatoid Arthritis
  Herpes
  HIV positive
  Hypertension
  Lupus
  Multiple sclerosis
   
  Other, please specify
   
 
   
  General illnesses, please specify
   
 
   
  Infections, please list:
   
 
   
  General surgeries/operations, please specify
   
 
   
  Current other medication, please list:
   
 
   
  Family History
     
  Diabetis
  Cancer
  Heart disease
  Stroke
  TB
  Kidney disease
  Blindness
  Cataracts
  Glaucoma
  Macular degeneration
  Retinal disease
  High blood pressure
  Arthritis
  Lazy eye
   
  Other, please specify
   
 
   
  Lifestyle
     
  Smoking: how often
  Alcohol: how often
  Drug use: How often
     
  Please tell any health information you think might help us treat you thoroughly: