Washington Eye Physicians & Surgeons

301-657-5700

5454 Wisconsin Ave, Suite 950
Chevy Chase, Maryland 20815

Medical History

Date of your appointment
*Date of your appointment:
 
Personal Information
*First Name:
*Last Name:
*Date of birth:
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Your Family Physician

Family Physician's Name

Family Physician's Phone Number
Family Physician's Address
City
State
Zip
Your Pharmacy

Pharmacy's Name

Pharmacy's Phone Number
Pharmacy's Address
City
State
Zip
Symptoms
Do you have any of the following eye or visual symptoms?

Vision problems while driving, reading or watching TV

Blurred or distorted vision
Seeing flashes of light

Redness
Webs or spots in your vision

Tearing, itching or burning
Light sensitivity

Lumps or growths around eyes
Double Vision

Drooping eyelids
Eye pain

Frequent headache
Frequent feeling of something in your eyes

Discharge
Other 
Please explain
Family History
Does your family have a history of:

Yes Family member(s) Yes Family member(s)
Personal History
s

If other Please explain

Do you take any eye medications?
If yes, please list 

Do you take any other medications or herbal supplements?
If yes, please list 

Do you have any drug allergies?
If yes, please list 

Have you ever had any eye surgeries?
If yes, please list and give dates 

In the past ten years, have you been hospitalized or had surgery?
If yes, please list and give dates 

Social History
Do you smoke?
If yes, how much? 

How much alcohol do you routinely drink?
Drinks per week?   

Do you exercise regularly?
Please list exercise activities, sports, etc.

Review of Systems

Do you currently have any of the following problems:


Frequent fatigue, unexpected weight loss / gain, chronic fever?
 
Ear / nose / throat problems (sinus, sore throat)?

Respiratory problems (shortness of breath, wheezing)?

Heart problems (chest pains, irregular heart beat)?

Gastrointestinal problems (heartburn, abdominal pain)?

Urinary problems (pain, discomfort)?

Musculoskeletal problems (joint pain, muscle aches)?

Skin problems (excessive dryness, rashes)?

Neurologic problems (headaches, paralysis, numbness)?

Psychiatric problems (depression, anxiety)?